04070165 CITY OF CUPE * �ry p N
BUILDING DIVISIONSION PERMITsC�L3, lklk` �'`lY;A s11�. ,
BUILDING ADDRESS:
ABLE SEPTIC 111111N'04070165
Z
0151 PERMITLSUEDATE
OWNER'S NAME:
PERCY DRY CLEANERS 920 REED ST ONE: SANITARY0. C NTROL NO.
(408) 377-992Q
ARCHrtECr/EtiGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION Job Descri tion
>: F I herby affirm dal I am licensed under pmvisiou of Chap.9(commencing P
Sz`� with Sec' n]%)of Dlviuon JofUn Basin
fessium Cc&.and my license is man fns (I E10D
ra dje��{_f�raay��—/(/���— ✓ INSTALL C lf_ LE 10D
i p Date 7 Convuwr ~�5 /O
1� �dan,pl:m"�:t W�a;;bit T om, JUL 30 2004
,'�n O LicePmfmani...I M
ip3ucd OWNER-BUILDER DECLARATION MOM
I herby affirm Nat I am exempt from the Coumctars License law for the
❑O fullnwing moon.(Sniun 7031.5,Business and Pmfessiuu Calc:Any city.r county
k m which Aqui.a permit io cnnslruct Ann,improv,demolish,m repair any swmum
Fiy prior to its ismerm.also rrquims the applicant for such permit to file a signed statement
<
that W is licensed promos In she previsions of the Connector's Lieut law(Chapin 9 Sq.Ft. Floor Area Valuation
2
A, danW bdngwith section 7000)of basis for
Rn he Bunnaampton.Ms And I Code)of
A,�� Nat he u exempt IMafram and the beau for tie alleged cumptim.MY violation of
Section 7071.5 by arty appli.,for A Permit son..the applicant A civil Pctnlly of et0 0 Occupancy Type
not moa Nan rive hurdled dollars($50)). r.
❑ I,m owner of Ne pmpeny,or my employcu with wages m Aseirmle eampcnutlon,
and dafessamt ands: he ComeaoAtintamedmaw seroma aply.toin water of Required Inspections
and enywh ou Code:The Convectors Liana law docs not apply to an owner is q P
.A enywhobuildsorimprovu Numn,andwho Aasauchwded oro eyed for sUghWe his
own employees,provided Nat such improwmmu see not intended mpledo.far We.IL
however.Ne Arm
ruimprovementis=to within one yen of UnprawiforNeawncr-
builder will rove Ne burden of provin6 that he did not build m improv for Purpose of
tale.).
❑1,As owner of the propcny,am exclusively contracting with licensed mnhinam to
construct the project(Sec 7066,Businm Aad Profeasus Code:)The Co-m -Li-
mom taw dors not apply to an Owner of Property who Wilds or improwa Ncaon,And,
who contracts fer such yrojecu with A mntractar(s)liamed pursuant to Use Contractors
License law.
❑lameaemptunar Sec .B&PCfofisassna
wner Date
WORKERS COMPENSATION DECLARATION
C-4 I herby elft.under penally of perjury ore of one following declare sons
I haw and will maintain a Ccrifan o(Conscnt self-insune fm WarkorsCompcn-
asud..,as provided for by Section 3700 of Ne tabor Code.for the performance of the
work for which Asia permit is issued.
I have and will maintain Workers Compensation Inst ..As aquiad by Safi..
3700 of Ute LsWr Code,far the perfa.uee of the wort forwhicli this permit is iuuM.
My Workers Compensmim Insurance artier and Polity number am:
a r. Q(VNK \ Policy No.. C (/L
CERTIFIGTE OF E%EMPnGN FRD DRKERS'
COMPENSATION INSURANCE
(Thu secure mW an,M ccmpiced if the Permit Is for one hundred dollars(S 100)
err less)
t certify that in Ne performance of the work for which this North is issued.1 shall not
employ any pcamn in any manner so a to baomembjeat to the Workers'Compensation
taws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifiatc of Esemption,you should
become subject to the Worker's Compensation provisions of the Labor Coda you muse
.,O forthwith comply with such provisions or this Permit shall W domed awkcd.
zCONSTRUCTION LENDING AGENCY
N
).. LahyAli.that thea iso nsvapr
uein.leading ncy for ft perform..of
C'�
Use
warWm
t for which thus .it u issued(Sec 3097,Civ.C.)
GA Lenders Name
=Z l.cndcis Address
V O I certify Nat 1 haw read this application and soon Nat the aWw info.adon is
U.F corm I agree N comply with all city and county ordinances and sun laws alating to
pU building construction,and herebyauNons apaunIdwS of this city to enter upon On
,r W aWuc meniomd property for inspection Purposes.
(Wc)agree to an.indemnify And keep harmless the City of Cupertino against
F',,0 liabilities.judgments,costs and cape".".which may in my way scam against and City s /
U Z in consequence of the gmading of this permit.
a-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: "'Date
SOURCEUL TIONS.
�)— -Et Re-roofs
Si ol'Appliart✓Convacoorsec
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant At future Wilding occupanumm or handle haavdous matmal
u deflated by Ue Cup esu a Municipal Code Chapter 9.12,and the Health and Safety
AftCodc.to..25533(6)? All roofs shall be inspected prior to any roofing material being installed.
Yu
Will sea applieaat or roma Wilding=Opel ase equipment or da.icea whim If a roof is installed without first obtaining an inspection,I agree to remove
emit ha7ardnu3air contaminants u dcftmd by the Bay Area Air Quality Management all new materials for inspection.
r District?
❑Yes u
Ihevc mad the hxnadaus renals mquiremeno under Chapar6.95ofthc Califon
nia Half&Safety Cock.Savom 25505,25533 And!25534.Imadermnd Nxifte Wilding
Ura not cyacnily naw a mnant Nm it u sm aspof.ccioy".oily de a spent of the
n{swf h Wmerpnatuaam araCerifiaNaf. pArq Signature of Applicant Date
0.1 c,— �
r or authnrieed seem Dan All roof coverings to be Class"B"or better
Community Development
10300 Torte Avenue
H Cupertino CA 95014
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRE �\�� PERMIT #
1 S, aY\ o� lo��) S
i
OWNER'S NAME• J` Pe PHONE 1- 13
GENERAL CONTRACTOR: FAX #
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 4
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
AO
/Contractor Signature ��Uate
' CITY OF CUPERTINO 0 7 o
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # ? / Date:
J ! U -0L
Building Address:
Io/51 ry 31� c�
Owner's Name J �� Phone #:
Contractor: n I L ` Poe: License#:
Contact: / � J ass I e>J Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job DescriptK. r� c
0,
Residential ❑ Commercol>,�Y
Cost of Project:
J 'f
a le Fee ID, Fee Description Fee Group
PPERMI'I'FEE 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