05020028 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: BAY AREA REPIPES PERMIT'905020028
OWNER'S NAME: FERMTT LSUE DATE
Ad�
igri nRAN E. GROVE DR
ONE: SANITARYNO. CONTROL NO.
(408) 371-5763
ARCHITEC,11NG1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED I amCONTRACTOR
under
DECORATION Job Description
E 1 Wmby affirm Net 1 am licensed under pmvisiona of Chapter Y(commencing P
iW with
imSeruon]odrIT fDivisionJof the Bovines sed Profrasi.ns Code.andmylicemcu
�« m�mroeanderr L Lie REPIPE/WATER SERVICE ��
S�_ Littn lea
n r Dale Contrxwr ff�f�
Y A
, RCHTIECI'S DEC P N ``�� s/(/1F-_,fllJkl \i\'
Y,< 1 undersand my plans shall he used u public records is
agis ,+n
wt�, Licensed Professional FEBr�YY
03 OWNER-BUILDER DECLARATION Eqqpppr
I 1 hereby a1Rr Nal 1 am exempt from the Contractor's License Law for IW 41111 1
O O following reason.(Secuun 7031.5,Business and Profession$Code:My city or county p
which reyconstruct,uirea a permit In stru ,eine,improvemom
,delish. ¢pair anNrt
Jury uure I' ADA F.iy, n
priorw iu issuance also mquins lure.,icant(.,such permitw File.signedscatra tn n
dot he is licensed pursuant to the provisions of me Cormacwri Liana,Law(Chapar9 Sq. Ft. Floor Area I—., U IL qN ValUatlon
amH (commencing with Section 7")of Division Sof the Business and Professions Code)or V
i�S that he u exempt therefrom and the basis for the alleged exemption. aJ Any violation of -
Section]031.5 by any applicant for a permit subjects the applicam I..civil penalty of 3 WV-Mrblbetenc 0 0 Occupancy Type
not moa man five hundred dollars(6500). P Y YP
I.aowner of the propany,or my employes win$wagaatheir salt compensation.
will do the work,and the structure is not intended oroRered foraak(Sec.]Ods,Business
and profession,Code:The Commencer Liana Law doe,not apply in an owner of Required Inspections
progeny who builds of improves thereon,and who dor3m ch work himxlfor Through his
co nemployees,provided NatsuchimprevememsarenotinandeA irradiated forsale.If,
however,the building or improve ent is sold within one year of completion,the owner-
builder will have the Wrdco of proving mat K did not build or improve for purpose of
sair)
❑1,as owner of ma property,am exclusively contracting with Iicaosed contractors to
construct me pmjem(Sec.7(64,Business and Professions Code:)The Contnewr's Li.
cave law dors not apply to an owner of property who Wilds or improves ft...and.
who concocts for such pmjem with a corn actor(s)licensed pursuant to the Contractor's
Lkcnse Law.
❑1 am exempt under Ser. .B h P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION -
1 hereby ruff under penalty of perjury one of the following declarations:
1 he ve and will mountain a CmLFicate Of Consent 10 self-Insom for Worker's Campers.
737W
tion,a provided for by Section 3700 of the labor Code.for the performance of the
ork for which this permit is imard.
I have and will maintain Wortrls Compcnsauon Iaunnce.a required by Section
or me labor Code,for the performance of the work for which this permit is issued.
y Worker' C pea(�s"ant 1 Unna eamicr and Policy numbbeer areme,"; oL{�Ir A(U Policy No,2�gOZ UAj;1,? -7 .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This schum need not W cumpleted if Ile permit is forore hundred dollars($100)
of Ica)
1 certify mat in the performance of the work for which this permit int Samara,l Shall not
employ any person in any commorN IS to become subject to IW Workers'Compcoation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificaw of Eacmption,you thmld
become subject a She Worker'a Compaction previsions of be Labor Code.you mud
=1 z foMwilh comply with such provisions or this permit shall W decmcd revoked.
Z'O CONSTRUCTION LENDING AGENCY
'p.�.. I hereby affirm that then is a construction lending agency for She performance of
he work for which mu peril u issard(Ser.309].Civ.C.)
ALcnder's Nam.
z Under's Address
U Q 1 ecnify mat 1 have read this application and sate that the above information is ,
ug f—' correct.l agree to comply with all city and county ordinances and scale laws relating to
CU Wilding construction,and hereby amhonm representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupenino against
F" fad liabil idea.judgments.casts anile acs which may in any way scant agarol aid City
U Z in conscgmnec of the granting this perit.
^ APPLICA USIPERST S AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
so cyL ( 3 �5— Re-roofs
Signal. o AppFi.anU on..,. Date '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will IW applicant or to,=Wilding occupant more or handle hazardous material
a de0ned by 0io Cupertino Municipal Code-.Chaper 9.13,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
pVa ON.
Will Inc 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 hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
wrier?
❑Yes C]No
I have marl the hvud1. awrialsmquim=naunderChapwrQ95ortWCalifor-
hisHealth6Safelycode, 25X)5,25533 and 25536.1 undersand und truce Wilding
docs no al iI h my reapnaihilily,w notify me occupant of the
ret m— I It., 'ssumec of a Ccrufr ofyk Pan�.bt
6 TT// LL GG�•''�- Signature of Applicant Date
Owner a.IM1on2dag<nl f Dale All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building De artment
JOB ADDRESS: PERMIT# Q) S--0 Z O 0 Z g
D D CLuv
OWNER'S NAME: Dq. o 4-1� PHONE #
GENERAL CONTRACTOR: q- Aria FAX #
I am not using any subcontractors: �a 6 3 a03'
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
2 ur7 $--
�/-Contractor Signature Date
CITY OF CUPERTINO
LN
REPIPE/SEWERS/MAIN SERVICE OsU�� v'2�
CUPERTINO PERMIT APPLICATION FORM
APN #
Building Address:20 ^D / C
Owner's Name& C fPhone#:6 Z 3
�dn n, (�
Cont r tor: Phone: License#:
rt i /- 6 3 Z'D/y'3
Conct: Phone: Cupertino Business License#:
Dk 11S nSan e�;-7 3
Building Permit Info:
Bldg- ❑ —Elect ❑ . Plumb(Id`
Job Description: /�
- - ] --. e-✓I FL/G/� vvse -- .4 t .Z.ti4 el_ S,, ✓r < C
Residential Commercial ❑
Cost of Project-
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
-BPERMFEE Bld . Permit Fees BUILDING
BPFIXTURE . Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE = Sewage Disposal PLUMBING
BUSLIC Business License BUILDING