03100064 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �$CONTRACTORA ORMATIO,N
a BUILDING ADDRESS: CUPERTINO PLUMBING PERMITN003100064
OWNER'S NAME: 10297 S DE ANZiA BLV PERMIT ISSUE DATE
NE: (4081) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
±00 LICENSED CONTRACTOR'S
under
DECLARATION
I ion 7 affirm that I am limned under provisions of Chapter 9(commencing Job Description
?pwith Section 101111)of Division 3 of the Business and Profession Cade,and my liana it
� in fCleend eff
z Liacountt_L ase 3� Corr G2� REPIPE
ARCHITECTS DE LLA nr 3/
) 1 understand my plaactor f
n shell be used as public rccnNs
c u.G t; Licensed Professional .
3
3 dim I am exempt fr m Ce Contr ON
0 q I hereby alum the 11. exempt from the Camracrofs License Law co the
O O followingneaten.Permit
t 9onstr Business and improve,
de on Code:Any oily s county
5$� which mquimsae,also ratchet to alms imprSuh Permit
me A Sig anystructure
ire shpriare its iensedp also requires the
so for Such Permitroctors icense Law(ned ommcnr
2zx fc, mmencingadpursuant ction7 th)ofDiaionnfthe oftheBwnessandProfeew(C apter 9ode)or Sq. F[. Floor Area Valuation
ejC (commencing with Section 1000)o(Division3nf the Business and Profcasinm Code)or
} that he is exempt thmcfrm and Ne basis for the alleged exemption.Any vinladon of 36909038 . 00
Section 7031.5 by arty Applicator for a permit subjects the applicant to.civil(costly of , e
not mom Bn five uhundred dollars(S500). - — -- ---APN Number. Occupancy Y TYp -
❑I.u owner of the property,or my employees with wages as their sole compensation,
will do the work,and the werure is not intended or offered for sale(See9004,Business — A
and Pmfeaim"Cade:The Contractori License Law does not apply to an owner of 202 — UNDER V G
progeny who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended oro0ered formic.If, 301- — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
Wildon will have the burden of proving that he did our Wild or improve for impose of 302 - TUB & OR SHOWER
ask.). 502 - FINAL PLUMBING ENERGY
❑I.eaowner ofer Sec.70,amezdusivnd contracting with:)The
eCconvectors to -- -
coeswctthe pmjcct(Sec.1004,Business end Professions Code:)Tbe Contractor's Li- 506 — GAS TEST
cense Law does not apply in an owner of property who Wade or improves Quinton.and, 507 — FINAL PLUMBING
who contracts for such prefects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑lam exempt under See. ,B&PC for this reason - -
Owner Dau
WORKER'S COMPENSATION DECLARATION — -
I hereby a(rnm under penally of perjury one of the following dedantitun:
I have and will maintain a Certificate of Conant to self-insum for Worker's Compen- ,. .
7031101"D
..,as provided for by Section 31W of the IaWn Code,for the performance of the .,
rk far which this permit is issued. .. -.
I have and will maintain Worker's Compensation Insurance,u required by Section of the labor Cade,for the performance of the work for which this permit is Issued.
Workces Compe/n/u��ion Insurance carrier and Policy number art:
rier: sCr1� .� Poli No.: V Z—
CERfII CA 0{E FLEX .1PnON FROM WORKERS'
COMPENSATION INSURANCE
(TTisactirm need not be completed If One permit is fortune hundred dollars($1001
or Ica.)
I cenify that in the perform me.of the work for which thio panni,u issued.l Mall not
employ any Some in any manners as in become subject to be Wmkers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code,you must
�O forthwith comply with such phwisinn or this Permit Shell be deemed revoked.
Z oCONSTRUCTION LENDING AGENCY
I hereby drum that them its ctunWninn lending upper for the performance of
a$> Ne work for which this permit Is issued(Sec.3091,Civ.C.)
1.1 ALender's Name
Z bending Add.. C, _
J C) I certify that I have read this application and state that the about information is
;^' cancer.I agree to comply with all city and county oninances and soon laws miring to
7 abonngeonswnioasnd herebyamhon p representatives of this city to coat upon tM
4 above-mc e)nedagree
to S property for emnity an Purposes.
ti
We)agree rtu ave,indemnify and kap harmless the Circ of Cupertino S id City
Z in
of Snaring es penes which may In any wayemsue egdntl Said City
J z APLIC mile of the Ranting of this rc 7.
APPLICANT UNDERST OS Will MPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG 5
/0�5-0? Re-roofs
Sign pelican a Actor Dale
ARD ATERIAIS DISCLOSURE Type of Roof
Will the applicant or f sere building occupamsare or handle hanNuusmaerial
a defined by the Cupertino Municipal Code.Chapter 9.12,and rhe Health and Safety
ale.Som,2553na+ � All roofs shall be inspected prior to any roofing material being installed.
Yu
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hurardmer air contaminants a dcfincd by the Bay Area Air Quality Management all new materials for inspection,
utricO
❑Y.S Hd+au
I have mad the hazaNnusmamnaurequimments under Chapmr6.95 of the Califon-
nix Health kSafety Code,Scedon,25505,25533 and 25534.1 umkmtsnd the if the Winning
does currently hart a mnan4 Nat it u my mspo iliiym rwdry tbe mc.P.nr o(thc
mgai mcnuwhi,h.. beret anthi ane .ce amaroccu occupancy. Signature of Applicant Date
o Q
ownerar a. Dam All roof coverings to be Class "B"or better
1 p o O
CITY OF CUPERTINO v ( g
REPIPE/SEWERS/MAIN SERVICE
= CUPERTINO PERMIT APPLICATION FORM
APN# r 62, Date: `G 9^v
Building Address: /
v d-
Owner's Name: (� � " Phone#:
Contractor: Phone: Picense#:
Cc-, t 2S-3— OG 18 C--)`j90
Contact: Phone: Cupertino Business License#:
rr-h L--
Building Permit Info: _ /
BldgEl Elect El Plumb LAY
Job Description:
O
Residential VM ICommercidl
Cost of Project: UUv J�
•
Qty. if
ApplicaFee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
B REPIPE 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 Business License BUILDING
-S