03080040 g
CITY OF CUPERTINO
PERMIT ,xLC'Ou,?N.,:TRABUILDING DIVISION . RINFQRMATION•
BUILDING ADDRESS: DIJOSEPH' S PLUMBING PERMIT"°03080040
OWNER'S NAME: 205 WYANDOTTE DR PERMIT ISSUE DATE
EARL WILLIAMS 11 2003
lip"Et (408) 365-2058 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a a o a
!00 LICENSED CONTRACT'OR'S DECLARATION .
I hereby affirm that I em licensed under provisions Chapter 9(commencing Job Description
with Section]M) cDivision J ofdm Businos and ,.(.Sion Code.andmyliccnseis
fullfortc.n cc
L .« 7c REPIPE & WATER SERVICE FDNnp�"[M
z Li.ensc cfaea
iF Dom Cumncmr
ARCHITECTS DECLA"TI9Ni
2 i'�nd my plans shell bSEP Je used As public records COO J
ryEs C I Licensed Pm(cssi.nal
s7 3 OWNER-BUILDE&DECLARATION BUILDING 2O O 1 hereby maso .(firm that I ore cBusin from nc Coniromurs License Law for the 9/ 6a d V
COO following mason.(Section]construct,
Business and w,da or.Code:Any city or county
$ which requires a permit to replimst a dmn improv,demolish,or repair any eummm . $7500
thtnnitscensed c.alwmyoiresThovisioso for such ContrarmttmoleaeLaw(Cammcm
sx< mat pursuant to he OfDialouofNeConuoctursLimnselaw(Chapmr9 Sq.Ft. Floor Area - Valuation
[tush (commencing with Seddon 71M0)o(Division)of the Buxirmss and Professions Code)or
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 35617051 . 00
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred della.($500).
1,as manor of the property,or my employees with wages As their sole compencolion,
will du the work,and the suucmm is not intended or offered for sale(Sea.]044,Business 3 0 L — ROUG
end Professions Codc:The Contractor'sLicerese Law don not apply to an owner of 502 — FINAL GL L�'RGY
propany who builds or impo.wa memo.,end who dueuuch work himself.,through his
own employees.provided that uch improvements are not ntended or offered for sale.It. 507 — FINAL PLUMBING
ho an.l.the building or improvement is sold wind.one yea of completion.the owner-
builder will Mae the burrn of proving that M did not build or improve fn purpose of
sale.).
❑ I.es Owner of the prnpcny,am exclusively contracting wish licensed convector to
construct the project(Sec.7(14,Business and Profusions Code:)The Conuacbr's U.
cense Law does not apply to an owner of property who builds or Improves thereon,and
who contracts for such projects with a conmeemrm)licensed pursuant o she ContractoM1
License Law.
❑ l Am exempt under See. ,B&PC for this..a.
11321.1W
ner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ore of the following declarations:
I haus and will maintain A Cenificae oFConsem m self-insum for WorkeYS Compen. -
ien,u provided for by Section 3]00 of rte labor Code.for the performance or the
rk for which this Permit is issued.
I have end will maintain Workers Compensation Insurance,u required by Section
of the labor Code.for the performance of the work for which this permit is issued.
W rker's Cnmff��euati.n lneonnq certicr end Polber art:r.
CERTIFICATE roucyR MWORK 1792 `hr I`
CERTIFICATEOF COMPENSATION INSURANCE WORKERS'
. COMPENSATION INSURANCE
(This section,reed not hccompmWal if the permit is fm.ne hundred dollars(giro)
los.)
1 Certify that in the performance of the work for which this Permit is issued,1 shall not
employ any permn in any manner so As to become subject to the Workers'Com,,msadon
Laws of California Data
Appliwm
NOTICE TO APPLICANT:If,arm,meting this Certificate of Eaempion,you should
become subject m the Worker's Compensation pmvtsiuna of me Labor Code,you must
.J z forthwith comply with such provisions or Nis permit shall Is,rcmed revoked.
Z OCONSTRUCTION LENDING AGENCY
[-+� I hereby affirm that there isocouuuctina lending agency for the performance of
C
be work for which this permit Is issued(Sec.3097,Civ.C.)
Ig1 Q Lender's Name
z Lenders Add..
V O I certify that I haw,cad this Applirnion and state that the Above information is
U,E C.meCL I agree 10 Comply with All City and County ordinances and cram laws ranting to
C) building construction,and hereby aumorim representatives of this city to ener upon the
117 shove-(We) W propene for indunify an keep hs.
(We)ogee to cove,indemnify and kith harmless the City of Cupenst id City
UZ in
of lts,Coatsind expenses thisrxwhicnthey inmyway ecome against mid City /
(, z A APPLICANT
Atha graining of this permit.
f—' APPLICANT NDERSTANDS ANO WILL COMPLY WITH A NON-POINT Issued by: Date
SOUR RE LATION �Ir
Afire
Re-roofs
ignature of ApplicamuCamracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will rte applinm or future building occupant nom or handle hararE.0 memo.]
ef at d by dm Collard.
u dMunicipal Code.Chapter 9.12,and the Health and Safety
ode.Scdion 25532(x)?
C]Ya �. All roofs shall be inspected prior to any roofing material being installed.
Will the applicants future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit haxurdnus air cmaraniamu u defined by nc Bay Arca Air Quality Managemens
isumt7 all new materials for inspection.
❑Yes
1 hove read she Imrardtmsmamriab requirements unrr Chapter 6.95efthc Califor-
ataHealth&Safety Cor,Secumts 25305.25533 and 25534.1 unr..M that if the Wilding
d.rmt currently hew A tenant that It isp�y espouNMI leKoury tM acupe t of the
Nyw�mf ts�wh �m�u�m�bcme ,foj,4uance.feCcui Occupancy. L Signature of Applicant Date
6�C""` r 'r � f jl P All roof coverings to be Class "B" or better
Owner or aushorind agent Date
CITY OF CUPERTINO v
wo REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# , Date: 7
?�6 —/ 7 - OS./ - rz
l� 7
Building Address:21716 7 3
Owner's Namei Phone#:
'toy � �i ��/ a g 2S 7-7Yy7
Contractor: JO S / S . Phone: 3� 5„ �, License#.-
Contact:
:Contact: 4 Phone: d Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description: 1�✓�N f�� 71
te-o( Ye---
Residential / Commercial ❑
Cost of Project:
•
Qty. if
AppliXbFee ID Fee Description Fee Group
PPERMTTFEE 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 Business License BUILDING