05030114 CITY OF CUPERTINO2 �'% - ' - �'
BUILDING DIVISION PERMIT CWbaC,TORhINFORMATION 'i,
BUILDING ADDRESS: PERMIT NO.
TERRY BROWN, GEN CONTRACTO 05030114
GERRiTIQ PQ I.GT 3i
OWNER'S NAME: PERMITLS'SUE DATE
'08
12
)NE: SANITARY ROL NO.
ARCHITEC[ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION O O O O
m 1 hereby affirm thus 1 am Ilamed under provisions of Chapter 9(commencing /a., e L/ _ / Job Description
i with Sation7IX )u(DiNsionJof Ne Busi� aMNofeasiom Code.udmylicenseis
n. in mB rola and effect .—ZG,( Z
;'q_ Liame--fJL'¢.a REACTIVATION OF #03110059
�—o Dam Contractor ORIG. #03110059 EXPIRED/PAID HALF OF FEES
q�q'�' ARCHIIECrS DECLAR 1
I understand my plans shall W used as public records
oyU
yoG Licensed Professional
5 OWNER-BUILDER DECLARATION
ip 1 Wmby affirm Nn 1 am exempt from the Conuecturs License taw for the
—00 following mason.(Section]W1.5,Business and Professium Code:Any City or county
y m which mquira a Permit lis construct.filler,improve,demolish,or repair any struaum �--
prior ba ins issuance,also mquirca the applicant for such Permit to f Ic aligned summent
Z?G that he is licensed pursuant to the provisions of to Comvclor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation 0
S
re F (commencing pt Sccs;or,and of Division tof he g B ed axe and exemption.Any
or � �
i�$ that k is exempt Oemlmm and the basis for the alleged eumpuon.Any violation of
Sccuon 7031.5 by arty appli erm fora permit subjcces Nc applicant m a civil penalty of APN Nbi 1 Oecapancy Type
not mart On fivehundred dollenyempm u. ,•�yL`� �1 '� J '
❑1,ss Owner of the property.or my employees with wages their a,lc Computation. Um
e
will do the work.and the structure,is nosintendcdmoffered Aging.(Sec.7044,Business _.r.+t l+"' a 0Y y
and Pmfceions Code:The Conmcmrs Liame Law does not apply to an owner of /r� U�ed I actions
property who Wilds or improve thereon,and who doe such work himse if m through his
own employees,provided that such;mprovomenu are not intended at offered for sale.If,
scaring.the building or imprownrem is mid within one year of completion.to owner- aJ
bwlder will have she burden of proving that he did ons Wild or improve for purpose of
saR.).
❑1,as owner of the propeny,am exclusively contracting with licensed contracmrs,o
co menet the project(Sec.7044,Buincss and Professions Code:)The Conlracmts Lt.
censecense law does not apply je an owner of property who Wildspor;mpro to Norton.and 1
who
,
La acs fon st apply
projects with a Owner onuacterty) ho pursuant the Lemon.and
License Lis .
❑I am exempt under See. ,B&P C for Nis rcazon �s�a e, a p
Owner Date
WORKER'SCOMPENSATIONDECLARATION -
I hereby affirm under Penalty of perjury one of Ne following declarations: %
3 h,ex andpm will for maintain a Certificateio3of Consent to self-insur the
Performance
ace of the
sauon,u provided for by Section 7]00 of the labor Cede,for the performance of the
work for which Nis permit is issued.
❑I have and will maintain Worker's Compensation Inwr4na,u inquired by Section
)]W of the labor Code,for Ne performance of use work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No,
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(ITU section reed not W completed if thc fermi,is forme hundred dollars(SIM)
or loss.)
I certify Out in the performance of the work for which this permit is issued.1 shall net
employ any person in any manners,as m lrecom�ubjrct m,hc Workers'Compensation
Laws of Califmm;a
ApplicanI JC�AA m
NOTICE TO A LICAWlrI f r eking this CeniTeam of Eacmplion,you should
become subject m the Worker's Compensation provisions of the Lahr Code.you mug
.,Z foMwith comply with such provisions or Nis permit shall W deemed mvnked.
z CONSTRUCTION LENDING AGENCY
Eve Ihereby affirm that None is a construction lending agency lnu Ne performance of
C' Ne work for which this permit is ins d(Sec.3091.Civ,C.)
(D 0 Lenders Name
z Icndcri Address�I /.
O Q 1 certify that 1 have read This application and sum On the Wee information is
Fcorrect.l agree to comply with all city and county ordinances and sure laws,dating to 01 5
0 mormngctioned iogand herebyectionsrepresenu,is�of Nisci,y reenter upon the I
ahovc-mcmumle proen,any hereby
inspection purposes.
Mines 1/`J.
F G (We)agree to save,indemnify and trop hvmless Uro City of Cupertino against
(� liabilities,judgmenls.costs and cxpns¢s which may in any way accrue against said Gly
U in consequence,of the gaiting of Nis Permit. 3-6���
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
s0 EGULAT(Op{5. _
3 — c' j Re-roofs
Signature of App icanUComacmr Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building occupant store or handle hazardous material
as defined by,he,Cupertino Municipal Code,Chapter 9.11.and the Health and Safety
,dNLCo&.Seedon 25532(an All roofs shall be inspected prior to an roofing material bei,
❑res �N, P P Y g g installed.
Will to applicant or mtum Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i,ba sedom air Contamianu a defined by the Bay Area Air Quality Managemem all new materials for inspection.
District?
❑Yes '
I have mad Ne bentlo smateriala requirements under Chapter 6.95 ofthe Caliror.
nu alth&Safny Coes.Sections;255115.25537 and 25574.1 unhrsuM Nat iflW Wilding
�� � t.Na,it u my fapomibilitY m,,Duty the occupant of Nc
tp' w;sseanceofaCcniGcalc3 p9ojSigna[ureofApplicant Dale
/ Date 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
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
l4T ( �� � t'� 2� 0s-03 o I 1Y
OWNER'S NAME: A--, -&t/ pi A PHONE # tf Oe 6 F1 - lcou
GENERAL CONTRACTOR'OL ".4A/ FAX # ocr-
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
66 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
2L,—
Owner/Contractor Signature Date
CITY OF CUPERTINO _
REPIPE/SEWERSIMAIN SERVICE c�
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
l2 03 1 2ov
Building Address:
Le, — 3 f cE (t2t h
Owner'sName: Phone#:
v
Contractor" Phone: License#: 3 G Z
Gr eacJ Ai Z`�J�(� I Dov
Contact: L. Phone: v Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
-11UL& L S _ pN— S1
Residential] Commercial ❑
Cost of Project �k
�I7 Uc> J .
f
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i eofFixturesPLUMBING
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