04050091 ' CITY OF CUPERTINO '° :� � *
BUILDING DIVISION PERMIT WeONTRACT,ORiINFORMATION `��-
BUILDING ADDRESS: CUPERTINO PLUMBING PERMIT N004050091
21721 CQLIIMBITq AV
OWNER'S NAME: PERMIT ISSUE DATE
igh FAITH WALTON
ONE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOp LICENSED CONTRACTOR'S DECLARATION
w 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
as with Section 7WO)af Division Sof NC Bust vs and Professions Coca,and my license is c���tl D
^�� in full force and effect. v%? Lic R�^C/!.2 - REPIPE/WATER HEATER REPLACEMENT`�" AL
L1 g Lzme, ra C�
Z—o Dam Cotillion
RITE ° - 1Df JUN 3 2004
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O� OWNER-BUILDER U ATIO BUILDING
IINIJIBy R R�g�llG
I hcrcb eRrm Nat I am mxcmpt firm Ne Contrutors License law for Nc c uv Ir v
Ho following reason.(Secuun 703173.Business Professing Code:Any city or county
K m which equirts a pesmil to ennsuua,alter,improve.demolim,or repair any structure
Fidprior to its issuance.also requires Nc applicant for such Permit to rile a signed statement
that he is licensed pursuenua thepmvising of the Conimcmh LicenY law(Chap.r9 Sq. Ft. Floor Area Valuation
FFG (commencing with Section 7")of Division 3 of the Business and Profraions Code)or
i Net he is exempt thc.fmm and he bub for she alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3WNIQuhE3eA0 Occupancy Type
No more Nen rive hundred dollars(SSW).
❑h as owner of she property,Or my employer wish wages as Nair axle compensation.
will do Ne wart.and Ne swcrm is net mounded or offered for sake,(Sec.]Oaa,Busters Required Inspections
and Prufesor w
siCade:The Coneme.Licerau no
Law does t apply to an owner of q p
property who builds of improwe Narcan,end who docs such work himself ar tNaugh his
awn employees,provided that such improsemmus;are not intended uaffmred for We.If.
however,the building or improvement is sold within one year of completion.the owner-
builder will have One burden of proving that be did not build or improve for purpose of
sale.).
❑1,as owner of the progeny,am exclusively contracting with licensed convenors to
construct the project(See.]Bda,Business and Professions Cade:)The Contracmr's Li.
term law does not apply to an owner of property who builds or imprams Nertan,and.
who conmeta for such projects wish a con=tor(s)licensed pursuant to Ne Contractors
License Law.
1 am exempt under See ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afrum under penalty of perjury one of Ne following dedanuor:
I have and will maintain a Certificate of Conserv in self-insure for WorkeesCompen-
.don,as provided for by Section 37M of the Labor Code,for the su formantt of due
O
for which Nis permit is issued.
W
have and will maintain Worker's Compensation Insuvna,as required by Sccuon
]OB of the labor Code.for the performance of Ne work far which this permit is iaamd.
My Works pe auonI nme& 'u and Policy number
�art:�y/_/�
Catricc me h PolicyNo.:�1 a� IIPs-t/1 CERTIFICATE OF EXEMPTION FROM WORKERS T
COMPENSATION INSURANCE
(Thu section rued not Wcompleted Ethic permit is foronc hundmddollars(SIM)
nr lass.)
1 eertify that in NC performance of the work for which this permit is issued,I shell not
employ any person in any manner so u m become subjuuo the Workcri Compensation
Law s of Calif.mi..Dau
Applicant
NOTICE TO APPLICANT:If,oris making Nis Certifies.of Exemption,you should
become subject to she Woher s Compensation provisions of the Iahor Ced,you muss
JZ foMwiNeamply with such mevising or Nis permit shall be dcemed mmked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that theme is a construction lending agency for the p,doncux:e of
Ga 7 the work for which Nis permit is issued(Sec.3097,Civ.C.)
14 ^n. Lender's Name _
a, Lender's Address
U 0 1 certify thn 1 have�7his application sole d n the above information is --
Iy Fcorrect.1 agree to comply w elicit and cou ,oWin tts and sate laws relating to
building runswciion.and .by ori¢rc renmti of Nis city mens upon J.
above-menuotrcd p(�lpc v fir it short pu
�a (Wc)agrehjo 1 do of end p NC City of C reform against
h IiabiliJes.jud is .and x tch may an yacc agaimtsair City
U Z in conYgce c f g in o is
^ APPLICA ERS .AND ILL- W ALL NON-POINT Issued by: Date
SignSOUtar Re-roofs
Sign arc of pp aHAZA'racmr Da.
HAZARDOUS MA DISCLOSURE Type of Roof
W' y the C pmonr fmure builI Code.
Cart stem or handle Bandit
and S.rial
u defin by du Cupertino Manic' 1 Code.Chapter 9.13.mJ Nc HcaIN and Safety '
sum. 0y.25532(1, il - All roofs shall be inspected prior to any roofing material being installed.
Ycn
ern thc applgant ar mtum builNNns occupent aY ayaipment ar deviate which If a roof is installed without first obtaining an inspection,I agree to remove
mit haazrdma air contaminants az Jc=d by the Bay Arta Air Quality Management all new materials for inspection.
District?
Yes /
I vi, adshe has nusm Is req rem ¢under haplcrti.95oflhcCalifor-
niaHcal & ctyCoca, cutins SUS,355 255 1 Jcrstandthmif Nc building
dor n cu fly Irc . n Pit is my on[bili m notify the occupant of the
rcqui en wI qlu m pormisSo dfaCcfica.ofOccup�a UCI Signature of Applicant Date
I U All roof coverings to be Class "B"or better
wnee o amh m,2d age.[ Da.
-Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS- PERMIT
�(t) /9 #
7/`7 Z ! � t�5 PV �j y QSoocl r
OWNER'S NAME: 2 PHONE # .T
GENERAL CONTRACTOR FAX # S -7
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 f
Roofing
Septic Tank
Sheet Metal 1
Sheet R
(/(
Tile
-J /Contractor S' atur Date
CITY OF CUPERTINO
REPIPE/SEWERS[IMAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
S/y,oy
Buildin.- Address: 2177- 1% ~7Z1
Owner's Name: rte/ /� �� Phone #: qq& -
Co i ractor: ��/J �/� Phone: , License #: y
vm l t7 ,
Contact: 11 Phone: r Cupertino Business License #:
Building Permit Info:
i
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of P ject:
Qty. if
a ie Fee ID Fee Description Fee Group
PPERIM FEE I Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING j
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
B SLI Business License BUILDING
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