04030133CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONATRACT�ORANFORMATION
,
BUILDING ADDRESS:
CUPERTINO PLUMBING
PERMIT ND. 04030133
OW NF.R'S NAME:
PERMIT ISf1E DATE
EMMY COP
ONE: '
SANITARYNO. CONTROL NO,
4 2
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
•
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
1 bereby affirm Nat I am Ii enscd under provisions of Chapter 9 (commencing
p
with Section ]WB) of Division 3 of the Biomass and Prefessiou Code, and my license is
mmnlmc anaerceet. GIDS
e
COPPER REPIPE
Lleenm Cl Lie. N
Date Contractor
�
AR Mr1ECTS DECLARAT ON
1 understand my plans shall W used as public rtrnrds
Ii.mtsed Professional
OW NEmBUILDER DECLARATION
1 hereby affirm Net I em exempt from Ne Contractor's License Lew far the
/
Co
ng mason. (Section ID3 L3, Business and csdnm Calc: Any city m county
Maso
tutee hnpmve,
which requires permit re con ms.
which i h, or repair any surnmen
h Per
requires the m for such Permit L rile signed maum.m
prior m its issuance. s ths,
FL Floor Area
meed pa4O
i,do. 9
thmhc isliccnwit pursuae tO visions of the License
Sq.
a [ton
)pm
eBusiness nPlsW(C ache)
with Sarefou ]000) ofDivision30(the a exe and Professions Calc) Or
dust In is exe li and ed Any violation of
that io is exempt burs for the alleged cvmant
3]ATN_q *1bgr00
Occupancy Type
or 10
atry aced MilrtfnrSW). rsubjects ted applicmuoaCivil penalty of
Any ap
nor roam than 0vc hundred dollars (5500).
mit me Man five
❑ 1, u owner of Ne propmy, w my cmployw with wage u Netr role compewtion,
Required Inspections
will do Me work. end the swctum is not inundcd m offered foram (Sse. ]0th, Business
and Professions Code: The Conuxmrs License Law does not apply to in owner of
property who builds or i m prove thereon. and who does such work hi msel f or through his
Own employees, provided that such improvements art not Recorded oroffered forsale If.
however. Ne building or improvement is sold within one year of completion. Ne owner -
builder will have de, burden of proving they he did nor, Wild or improve for purpose of
sale.).
❑ 1, As owxr of Ne property, aro exclusively contracting with licensed coronation; to
concoct Ne project (Sec. 70", Business and Pm(essiorn Codo:) The Contractors Li-
'
cease Law does not apply to an owner of propery who Wilds or improves Ihemon, and.
who contracts for such pmjecu with a cmnVmtoa(s) licensed pursuant so the Contractors
License Isco.
I am exempt under See .B&PC for Nis mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby efaon under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to scl6insure for Wor4sr'sCompen-
ssdon. As provided for by Section 3700 of Ne ItWI Code. fm Ne performance of the
work for which this permit is issued.
have and will maintain Workers Compensation Insurance, As seyuired by Section
]OOof Me Lmor COde, forted d...f work for which this permit is issued.
My Worker am neatir rv�tmlFearner Nd POlieymanber Le:
Comer. % Ise\ Policy No.: OOO _(�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
MRs section need not he mmplm al ifthe permit is foram. hundred dollars(Silky
or max.)
1 cerdfy that in the performance of Ne work for which this Permit is issued. I shall not
employ any person in any manner an As in become subjen to ted Workms Compe mdm
Laws of California. Dam
Appimarn
NOTICE TO APPLICANT: If, after making Nis Certificate of Exemption• you should
become subject in the Worker's Compensation provisions of Me Labor Cate you most
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 heathy off rat Nm Nemm ais . a construction lending agency for the perPormen a tar
' Nc work (tar which this permit is issued (Sec. JOY], Civ. C.)
lender's Nun.
lsiWer's Address
j I renify, Net 1 have mad Nis application and sum Nat Ne shove information is
'
' commit. 1 agrco to comply with all city and county ordinances and sum laws relating to
building cit'nis�ru9tim, and hembyauth . rtpresenutnes of Nis'u,1. am, upon Nc
aM1ovcmemi.neH PmpenY( tips pas s.
(We) agree m save ndem , y and cp humlcsa NC City rf Cupertino against
j liabilities, juJgniems. c and0 uas no may in any way accrue against mid City
in eoueq� of the raritin f his it.
' APPLI M. RSTA j1eL COMPLY WITH ALL NON -POINT
Issued by: Date
SPUR RE ON
Re -roofs
Type of Roof
A u man vac r Dau
HAZAR US AIS DISCLOSURE
Will the applicant or future building occupant store Or handle havardous material
az fined by ted Cupcnino Mun al Code. Chapter 9.13. and Ile HnIN m0 Safety
we. pro 3ss3z(a)'!
All roofs shall be inspected prior to any roofing material being installed.
o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or None building Occupant use equipment or&view which
it haran nu air coruminanu az dcrined by ted Bay Arta Air Quality Management
all new materials for inspection.
District?
Yits
Ih. ed ead m� myuirtrnenu under Chapter69y of thisC lifor.
ria H..IM myCodc -23 15537 and i55Ja.1undcrslmdthmifNC Wilding
docs not Y h a Nn 'Na t' t(y reaponsihilitY to notify the acupant of
mquirt 0 n e m«erac.n;n pan.y._
(Date
Signature of Applicant Date
All roof coverings to be Class "B" or better
n.r r thariecdag t
4TYOF
UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS-
PERMIT #
/3 -3
OWNER'S NAME:
PHONE # s 7
GENERAL CONTRACTOR: Plrl�G
FAX #
J
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
H FA
AF INA
(�i _
Date
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 117 /7
Tile
H FA
AF INA
(�i _
Date
I '
s
0
[I
aClTyf
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE 3 3
PERMIT APPLICATION FORM 3
APN# I Le � 1
Qty.
Plumbing Permit Issuance
PLUMBING
Building Address:
�CJT �� � { 1✓S�� �i
Re i e of Fixtures
Owner's Name i V 7�
P one
262 577
Contractor:
`Phonie}77 i
License #/6g)�h b5—
5
Contact:
Contact:,
2�bOl
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect El Plumb M/
BPWS VCS
Job Description:
PLUMBING
Residential Comme cial ❑
Sewers
Cost of Project:
41v C>(--) -
vC>(--)-
BPSEWAGE
Qty. if
Aoolicable Fee ID
Fee Descrintion
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
BPWS VCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
I-v*TY-1