05030330 CITY OF CUPERTINO
BUILDING DIVISION PERMIT <CONTRACTQRINFORMATION ,
.k, m•P.:aa. ...X< d $ l� xx�_dx as.,Ax$„ i4"'
BUILDING ADDRESS: PERMIT NO05030330 5030330
OWNER'S NAME: PERMIT ISSUE DATE
ARW WAN Mr,
ONE: SANITARY W077 OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB. MECH
e00 LICENSED CONTRACTOR'S DECLARATION Job Description
WOto
C I hemby affirm Nal 1 am licensed under provisions of Chapter 9(commencing
U with Scaion'/IXlll)nf Division Sof die Businosx and Pmfcssinas Code.end myliccnse is
n full fo¢e and effete
�jK in
Class Lk.g CITY CLEAN OUT
ZFl Dam Cog*S DECLARATION EE ARCHITE Y
C< 1 undersand my plans shall M used u public records
3ciU
''0� Licenced Pmfcesional
❑ 3 OWNER-BUILDER DECLARATION
d<I 1 hereby affirm thm 1 am exempt from the Contractor's Liccnm Law for the
00 following as .(Section]1131.5,Business and Profession Code:Any city of county
K$� which¢quires a permit m consumer,alter.improve,demolish,or repair any structure
Is prior m its issuance.also requires the applicant for Rich permit to file a signed summem
that he is licensed pursuant to Ne provisions of Ne Common's License Law(Chapter 9 Sq.Ft. Floor Area Valua[io
ne (commencing with Scedon70)0)of Division 3 ofthe Businessand Professions Codc)or
y that h,u attempt therefrom and the baso for the alleged csempti.n.Any violation of
Section 7031.5 by airy applicant fora permit subjects the applicant to a civil penalty of 3 GVVI TT*grp p Occupancy Type
oat roam than fire hundred dollars(5500).
❑1,as owner or the property,or my employees with wages as their sale compensation,
will do be work,and the swctum is not intended or offered for sale(Sec.TBX,Business
and profcelimis Code:The Commcwrs License law does M1 apply in an owner of Required Inspections
progeny,who builcism improve Roger,and who doessuch work himself orthrough his
own employees,provided that such improsemena arc not intended oro@red Image.It,
however,the building or improvement is sold within ons year .of completion.the owner.
builder will ban dre burden of proving that W did not Wild or improve for purpose of
vie.).
1,as owner of the proparty,am exclusively contracting with licensed eomomma to
conswcl the project(Sec.7W,Business and Professions Coda:)The Contractor's U.
cera(law does not apply in an owner of property who Wilds or improves demon,and,
who concocts for such pmjccts with a conuaclogs)licensed purati nl to be Commialm's
Lt. .-law.
❑lam exempt order Sce. ,B&PC for thisrcsson
OwnerQVW Daa
COMPENSATION DECLARATION
1 hereby affirm under penally of perjury,ane or the following declarations:
I Aare and will maintain a Cer ificaaof Consent to self-insum for WorkersCampcn-
ation,us provided for by Section 3700 of the labor Code.for the performance of she
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My WmI ce,Compensation Insurance conic,and Policy numbs,ao:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu action need nor W completed inhe permit Is frrone hundred dollars(slip)
or less.)
1 canify that in IW performance of de work for which this Permit is issued.I shall not r
employ any permn in my mmncrms 1 e subject m the Workers Compnlsxtion
Laws or California.Date Q
Applicanty�,,,,_
NOTICE TO APPLICANT:IL Tlci making this Cer iBca¢of Exemption,you should
become subject he the Worker's Compcmution provisions of the Labor Code,you must
.J O forthwith comply with such Provisions m mit this pershall be deemed revoked.
z� CONSTRUCTION LENDING AGENCY
[r I Witty aRrm that there its emuumetinn lending agency for the Performance of
7 the work for which this permit is issued(Sec.3097.Civ.C.)
Lenders Name
= z Lenders Address
U O 1 certify that 1 have mad this application and sit o that the shove infornatiun Is
f" collect.1 agree m comply with all city and county ordinances and sure laws miming to
U Wilding consrniclion,and hereby autthnne repracnurivcs or this city to enter upon the
W above mentioned pmpcny for inspection purposes.
(We)agree to ave,indemnify and keep harmless the City or Cupcnino against
i N liabilities,judgments,costs and expenses which may in my way scenic against said City
V z APPLns permit.ICA INDERSTIANDS Aof IND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEE ATI
ULO�IS. �\�' �,✓
I \ 1 Re-roofs
Signature of IicanVConuacmr Dam '—
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Inc applicant or future building occupant sore for handle havardous mammal
as defined by the Cupertino Municipal Code.Chapter 9.12,and be Hcalth and Safety
Code,Section 25532(x)? All roofs shall be inspected nor to an roofing material beim
❑Yea �Nn P P Y g g installed.
Will thea llconr orf Lure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I PP g p yuipmcn
it sonorous air onntuminan defined by the Bay Area Air Quality Management all new materials for inspection.
isuict?
❑Yes No
1 have read the havNous materials mquimmenu under Chapmr6.95 of the Califor-
niaHeallh&Sof y�.rodc,Scnios25505,25533 and 255X.lundcouM but if the Wilding
dors rest Imen an a ananL that its my mapmmihiliym rmdfy the occupml of dK
requimmenss mustWmetPrior tuisaumauraariBeareoraeupmcy. Signature of Applicant Date
I11 All roof coverings to be Class"B" or better
Owner Lir authmd d agcm Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
SUPEI�TINO
Building Department
JOB ADi�RESS: PERMIT #OSo3 0330
Yi`i I Sl WdrA7 0(.
OWNER'S NAME: aTiZw PHONE # y -7.,3C
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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
e
Owner/Contractor Signature Date
c75 03 033 0
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM .
APN # j b -37 -o) Date: 31.05
Building Address:
Zai S C-11 X06 w
Owner's Name: rk W Ocie N Phone#:
`f`t6 2-636
Contractor: Phone: License #:
Contact: Tc,n e, n I Phone: o Cupertino Business License #:
Iv 4�6-46�
Building.Permit Info:
Bldg ❑ Elect ❑ Plumb 0-�
Job Description:
Lid GJ7
Residential Commercial ❑
Cost of Project: }hZo000
�7
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbin.g Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Dis osal PLUMBING .
BUSLIC Business License BUILDING