03060012 CITY OF CUPERTINO ` a�M f m
BUILDING DIVISION PERMIT 0N'TKkt:TQR�TN�'O ATIUN .
BUILDING ADDRESS: ALLSTAR PLUMBING PERMIT N003060012
7 80 DE LA FARGE OR
OWNER'S NAME: 656 N KING RD P"" ""'ffn2/2003
HIBERT LOUIS R AND MONA
NE' (408) 251-6040 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ndI thereby affirm LICENSED I CONTRACTORS
�under provisions of Chapter 9(comma ng Job Description ie;�,��®
Muff Section? )ofD"' 3oftht Bulnemanci Pf to C ylice Is
D4=n amnmmea SEWER LINE ZOOS
Llcen.0 Lk.g JUN U Q
e D.te can
ARCNI'IEc7rs DEC ON
.r Wdprwnd my plana shall he used u public meords BUILDING
Is �V
G Licensed Professional
9 OWNER-BUILDER DECLARATION
4 Q Z 1 hereby.sect o n I a1.exempt from the Gonl.mC o License Lew for the
loo followingmoan.(Sedan 703 1.5,Buaher. end Profeainns Code:Auteuil or county
.�$tial which requites issuance.else re conaaual eben W prrw,de ermit i m rtpWr any moment
Priormitaensedva requires nbe i,i...f forsuMe Cchpertnilwricruele a signedw(Cha menr
i < (does commecanseupa.aamwtheofDialaronrNceam.ness.narselaw(ChaPter9 Sq. F[. Floor Area $�Qo$[IOn
$ that he is(commencingwith Section7000)and of basis
rth Al Busiaged eampt Professionslatdc)on of
Net be u exempt tbem(mm and the buil for tiro elle{ed europeen.Any violation a(
Section 7031.5 by any applicant fm a Permit ubjects the applicant to a civil penally of
not more Nan Five hundred doll..($500). e+' Occupancy Type
❑1.ea owner of Ne property,or my employees with wa{es u their sale compensation.
will do the walk,end Ne swcwm is all blamed of offered for ole(Sec,7044,Business
and Prefesslom Code:The Contractor's License Law does not apply w an owner of 2 02 - UNDER `NG
property who buildsorimprows Nemon,and who doe suchwork himselfor thmu{h his
own employees,provided than such improvements ane not intended mutilated for sale.If. 301 — ROUGH PLUMBING
however,the building or improvement is sold within rote year of completion.the owner
builder will have the burden of proving that he did not build or Improve(or purpose of 507 - FINAL PLUMBING
ale I.
❑1,as owner of Ne property,am exclusively contracting wife licensed rnntruwn to
counmct the project(Sec.7014.Business and professions Cade:)The Can es ton's Lb
ccue raw does not apply w an meet of pmpeny who Wilds or improves Merton,and
who convects for such projecu with a cantracmr(A licensed pursuant to tea Canuactor's
License raw.
❑1 am exempt under Sec. ,e R P C for this reason
1301.0,'0
ner Oata
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penahy of perjury ane of the following declarations: -
1 have and will maintain aCenifiose of Conant w self-insum for Warkeis Compere
on,u pmvided for by Section 37M of the Labor Cade.for the performance of fee
for which this permit is issued.
1 have and will maintain Wortr/a Compensation Insurance,a no ddred by Salon
of the labor Cade,far the performance of the work far which this permil is issued.
Workcls Compensatpn lnau artier end Ir, miser am:tier PNC/L7 r<poE .
CERTIFICtoi OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need non c completed lithe rated,is froom hundred dollars(SIM)
or leu.)
I cenify Net in the performance of the work for which this Permit u Issued.I Nall not
employ any person in any manner an As w become subject o the Workeri Compsmaton
Laws of California.Data -
Applicant
NGriCE TO APPLICANT:IL after making this Certnute of Exemption,you should
become abject w rhe Workeri Compensation provisions of rbe Labor Code,you must
Z forthwith comply with such provisions or this permit shall be decreed revoked. '
z O CONSTRUCTION LENDING AGENCY
[••i 4 I bermy alrvm that there is a conawctlnn lending ageruy for me Performance of
ai? Me work for which this permit is issued(Sec.3097,Co.C.)
�0 Lendcri Name
z, Lender's Address
U 0 1 coolly Nal l have read this application AM sum that the above information is
,w
came 1.1 agree to comply with all tiny m aunty entrances and state laws telling w
O U building convection,an embyaathori repressmadwe of Nis city to enter upon the
W
above Proper far tnapectla amuses.
L1a (Wc).arta to ,indemnify d trop harmless the City of Cupertino against
N I biilex.jud as and exptn which may In any way nave against said City
U in conseq oaf the of Nis omit.
G APPLIC UN AND WILL COMPLY WITH ALL N INT Issued by: D e
SO R GULA
Re-roofs
S' eture afApplicanVZARDmr ...
HAZARDOU MATERIALS"homaDISCLOSURE Type of Roof
WIII Ne applinm or tutu tiding eccupant Hort or handle Health and
As defined by fee Cupertino Mu cip.I C. Chapter 9.13,and the HaIN and Safety
ode.& y.2563x(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye No
Will the applicant or future bud ins pant sec ext pmcm or dc,4.which If a roof is installed without first obtaining an inspection,I agree to remove
it havardous air eanuminan u lined y Bay Area Air Qualhy Management all new materials for inspection.
tr ct?
❑Yu
Ihav ehasa smucrie viremcros under .Chapter 6.95 altee Glifoo-
ni.H..IM yCade. btu 33 and 25534.1 undersand dw time Wilding
does not cu yhawa an tri responsiMliny m nods upart of the
mquireme khroust m tau or.Carol, (r ap Signature of Applicant Date
nerursuNomcdagem Date I All roof coverings to be Class"B" or better
� l CITY OF CUPERTINO O j
REPIPE/SEWERS/MAIN SERVICE
CUPE1INO PERMIT APPLICATION FORM
APN# pA �r� Date: Z,
Building Address: U /
Owner's Name: Phone #:
Contractor f� / ' , 4104e: License #:
Contact: (/L Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ PImb
Job Description:
Residential ❑ Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE BI d . Permit Fees BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
tBPWSVCS Main Water Service PLUMBING
PSEWER Sewers PLUMBING
PSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License I BUILDING
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