05050023 CITY OF CUPERTINO " ' - I•
BUILDING DIVISION PERMIT `CONTRACTOR4INFORMATION
BUILDING ADDRESS: PERMITNO.
DIJOSEPH' S PLUMBING 05050023
OWNER'S NAME: PERMIT ISSUE DATE
4HFN0—T7 T TTQ
ONE: SANITARY OL N0.
ARCHITEC iENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
200 LICENSED CONTRACTOR'S DECLARATION Job Description
U-F 1 hereby affum Nm 1 am licensed under provisions of Chapter 9(commencing
U wiNscetiory7")ofDivision3ofNCBeat.aMProfcssiuvCoem.andmylicenseI, ® p p
"'4 '"`u°`°rt ;°d"" C Lie.. '��� " REPIPE & WATER SERVICE ����Y�� ®
5 qv, Licen:<Cho `�
w Dam�S V s Cumracmr 1 n
ARCHITECT'S DECLARATION
? U1 understand my plans shall h ..,it,
used as Public
"l- Licensed Profcrosional /�� `Z005
I OWNER-BUILDER DECLARATION
eF 1 hereby affirm Not I am exempt from the Comnctors License Law for the
E aa fallowing remoM1(S Wyn 703I.S,BLLShKls and PlofeSV°n{Code:Any coy or county
K m which requires a permit to ennswct.slier,improve,demolish,car.,.it any structure
poor to its issuance.also requires the applicant for such permit to File a signed statement
— < thatheisliccveJputsvanuntWprovnsiovpftheContracmr'sLi¢nselaw(Chapler9 Sq.Ft. Floor Area U
Y~$ (commencing with Section 7MO)of Division 3 of the Business and ProfestionaCMc)or
'yu _
that he H exempt therefrom and the hub for the alleged eumplion.Any violation of
Section 3031.3 by any applicant for a permit subjects Nc applicant I"a civil penalty of 3 y>aVEVM4l 1p p Occupancy Type
not more Nan five hundred dollars(SSW).
❑Lvowner of the property,or my employer wird wagva Ncir vol<compcnvtion,
willdathewoh andtheswelumunot intendedoroffert forsalt(S .7 W,Businaxs
and Profusions Code:The Contractors License taw ears not apply Or an owner of Required Inspections
property who builds crimproves theroon.end who docssuch work himselfor through his
Own employscs,provided that such impmvemcnu am not intended or offered for vie.If.
however,the Wilding or improvement is sold within one yeti of completion.We owner.
builder will have the burden of proving Nat he did not Wild or improve for purpose of
vl,J.
❑h as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7049.Business and Professions Code:)The Contractors Li.
cave law docs not apply to an owner of p.,ny who W ildm ar improves thereon.and
who contracts for such projects with a eontricau(s)licensed pursuan to the Contractor's
License taw.
0 1 am exempt under Sec ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty or perjury one of the following declarations:
4 �Ihim and will maintain a Certificate of Commit,self-insumfor Workers Compen-
sation.as provided for by Section 37W of the Inbar Code,for the performance of the
J work for which this permi t is issued. .. „
1 have and will maintain Workers Compevmion Insurance,as required by Sccuon
37W of the labor Code,for the performance of the work for which this permit is issued.
My Wmrkcr's Compensation InsuranceCar^ier Mid Palicyn ht art'
Cartier. �N1+PY S lUl PolicyNo.:
CERTIFICATE OF EKEMPT30N FROM WORKERS'
COMPENSATION INSURANCE
Cnis section need not becomplacd if the permit is formic hundred dollars(SIM)
or less.)
I certify that in the performance of the work rot which this permit is issued.I shall nut
employ any person in any manner so as to become subject o the Worker!Compensation
Laws of California.Date
APPlieant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you shuuW
become subject to the Worker's Compensation provisions of the labor Code.you most
.JO foMwith Cerro,with such provisions M Nis permit shall the m
e de4ed revoked. '
ZN CONSTRUCTION LENDING AGENCY
[-. 1 hereby affirm that Vert is a construction lending agency I'af Ne performance of
a 7 Ne work for which this permit is issued(Sec.3093,Co.C.)
uj Lender's Name
1 Intler's Addrss
U 0 Q
U J 1 certify that 1 have read Nis city
and County
and mute that and
above information
ng is
0 U cuildin 1 agree to comply wird all city and county ordinances and state laws r Upon
m
� w abovengconstruction,tioneand hereby authorin:rrows. Lives of this city to enter upon the
t 0. above-mentioned are to ertyream for crani fy an keep h.
�, W es judgment,
agree t"uses Indemnify and keep hamlet the City memo
against
W in
aunce of thecostsang expensof thisvmit. may in any waya<cvc against mid City
V z APPLICANTeUNDERSTANDS ANDWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR RE ULATIONs�f o 1
( e /7rO S-y'1 fk Re-roofs
Signature of ApplicantKon mkn" Dam
HAZARDOUS MATE ALS DISCLOSURE Type of Roof
Will the applicant or future building occupant smrc or handle hatterous material
u dcfmcd by he Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
tuns Ne app m on of future building oeeupant use cqui or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit baafdnus air,'mx=namm am defined by the Bay Ama Air oaafity Management all new materials for inspection.
District]
❑Ya ON.
1 have mal Ne Wallous maw6alswquim=nu un kr Chapar 6.95 of the Califon
v ni,H lth&SafctyCa ,Sasso.2M5,25533and25534.1undcrwvmthaifthe Wilding
doesn n¢n wMm of currently have a u n t,that it is my responsibility nouly the oscupant of the
regairoses Wain to tanwisfuanecoacerufaamorocan cy Signature of Applicant Date
(An ^
Owner to tuari.d agent — I
au /'
Dem All roof coverings to be Class "B"or better
ate. Community Development
k 10300 Torre Avenue
L Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPE(�TINO
Building De artment
OB ADDRESS: PERMIT #
I 0/l CAq &,r✓/La b/- �c�'riyNO (aSOSav2
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: 3(, S'-20�'
I am not using any subcontractors: �D (/ S° y 5�
,
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
® Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry.
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
(SamREPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# � Date:
�/ -,23 -- 06T - a0
Buildin� /67 ss: /NCC(iQ SiR
Owner's Name: ( Phone#:
S� Ph �z � / h 7SS�- y8��
Contractor: OJd S Plp4 S Phone: 3 20 5� License#: S119/G-y-
.r�+�
Contact: /�I y _/� Phone: 3 Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
rf /,",P f 6c-al-e/-
Residential
c-A -P/iResidential Commercial ❑
Cost of Project: r, 7 % O o
i r
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC I Business License BUILDING
i�
237, �