04010126crrY OF cupwrINo
BUILDING DIVISION PERMIT
CONTRAC rQRaINFORMATION[r
9f"5i°ei; i. .�,�" vfANF
BUILDING ADDRESS:
L0871 W FRTATRS DR
PERMIT NO. 04010126
OWNER'S NAME:
PERMIT ISSUE DATE
DAVID MORRIS
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR DECLARATION
do Chapter 9
Job Description
P
y affirm ma 1 am Ilansed u sof (commencing
wih5 on acct of Division 3of/hc Rusircsa hofessi Cod. aM my license is
n/
mthly. mderreet. !/C•) % 8'O
REPAIR SEWER
Licen las Lie.g
Da C.nlr r
CONTRACTOR: PLUMB-A-WAY
CHITEM S DE ATION
I uMcrslaJ4 ,}I he ued s
/mffd_ -3 MI/t
Licensed Proramal
- BUILDER DECLARATION
I M1crchy affirm that I am exempt from the Contractors Law fur
Any
my
c
following rcamn. (Section ]1131.5, e. : Any city .,aunty
and Prooic.de
which construct. alter, imprn e, demolish. repair any
demolish.
which plots h.or
sams a pmmit
fi
statement poor
itscensedpalsosequins tMapplicant for
its m
Sq. Fl. Floor Area
CoM1permit LfI,asignedsummcnt
that cmnscdpursumw.the the ComranesiucmeminasC(Chapter 9
a
Val uat 500
(commencing with ofDprevisions onf
n. or
pthection refromm)BW baiisfrnnneeueinexemptond
AnyvilatWe)
Net his exempt therefrom and the breis for the alleged exemption. Any violation .f
APN Number
Occupancy Type
Section ]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
nor mine Ban fihundred deltars 430(d.
Pane Y YP
36923042.00
❑ I. is owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work and the suuetun is not intended or offend for sale (Sec. 7044, Business
and Professions code: no Comocmretpe s LieLaw docs not apply to in owner of
property who builds or improves thereon, and who does such work him odr or through his
own employees, provided that such improvements ue not intended or offered for sale, If,
however, the bottom& or improvement is sold within one year of completion, the owner.
builder will ban the burden of pmving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
cons, a project (Sec. 7044, Business and Code:) The Contractors
property
ofpropcny who buildsor improve melon.and.
it who nd
,eve Law dotsnot apply man
with
for such proKets with a Convanor(s) licensed pursuant to the C.nVactpts
oo.
tcI Law.
Law.
em eacmpt under Sec. B & P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury om of the following declaratioe:
I haw and will maintain a Certificate of Consent to self-insum for Worker's Compcm
sat ion, as provided for by Section 37W .f Be labor Code. for me performance of the
work for which this permit is issued.
❑ I have and will maintain Wmkcri Compauat for Insurance. as required by section
37W of Be labor Code, for the performance of Be work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carriac Policy N..:
CERTIFICATE OF E%EMPr10N FROM WORKERS
COMPENSATION INSURANCE
(Tbu sectma nced not tecompleted if tbe Permit is forum hundred dollars (S IN))
,r thsa)
I ccnify tha 'n the if oni nee of B, ark for h' h Bis permit is issued. I shell not
min an mamrf be .0 to me W.rkcrs'Com nsmion
Laws of Cad a.Dam` deo' 4+`r —
P Beam el
N ICE TO APPL ANT: If, r maki is Cenificate of Ezempti... you should
come subject to the Worker's Compensation provisions of me Labor Code, you must
."with comply with such provisions Or this permit shall w deemed n olcrd.
CONSTRUCTION LENDING AGENCY
1
I hereby affirm that there is a mTULnieinn lending agency lot the Performance of
-
Be work for which this permit is issued (Sod. 309], Civ. C.)
lender's Name
Leader Address
1 ccnify But 1 have read this application and state that the above information is
Correct I agree to comply with all city and County.Ninances and store laws relating to
building constitution. and hereby authentic rcprosemati es of Bu city to enter upon the
above-mention property for iropechon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,p gm,nu, ensu and,.pedes which may in any way scum, against said City
in conseywwe of one granting of this Permit.
APPLICANT U NDS AND WILL LY WITH ALL NON-POINT
Issued by: Date
SOURCE LA S.
Re-roofs
-noun of Ap ni/ConuaetorDam
HAZARDOUS MATERIALS DISCLOSUR
Type of Roof
Will Be applicant or future building Occupant store or handle M1a.ardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
we. Schon zss3nan
All roofs shall be inspected to any roofing material being installed.
❑m.
Y.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the appliantm morn building=upon( use equipment or devices which
it ]nitrations air conaminanu a defined by Be, Bay Arta Air Quality Management
all new materials for inspection.
sbin] `/o❑Rs
I
Q`iN
I have pew Bc hamNous materials nquitcmcnu underCludde,6.95 ofBe Califm-
Health & SaRtyCode, Samms 255(15.25533 aw 25534.1 uMkrstand B t if the building
es not e.memly have ret Bait is m apmomility m m,uf Occupant of Be
qujm It t atutimmis an,.f.Cwram
$ignatt of Applicant Date
All roof coverings to be Class "B" or better
oucor mh
r cued a Dare
J
0
•
sma
CITY OF
CUPERTINO
CITY OF CUPERTINO D
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
I I,
APN # .2
Date:
Re i e of Fixtures "
PLUMBING
Building Address:
6 g -? L
Bldg. Permit Fees
BUILDING
Owner's Name:
Pbl . Fixture
Phone #:
UA
Main Water Service
t/yG
Contractor: Phone:
Sewers
License #:
LomIS A-600
YoT -391-0530
?k99-63
Contact: Phone:
Business License
Cupertino Business License #:
Ctkff-r c, GU&vyr,v
391—oq-
uilding- e t Info:
Bldg Elect ❑
Plumb
Job D ription:
2GP A Z2 S r w r– /7— Ul' 'T 0
PEs 7 --xy f 7 fI2
Residential PfCommercial ❑
Cost of Project:—
Qt
A liy1 if
r2 h) e Fee TD
Fee Description
Fee Grouo
PPERMITFEE
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 Dis osal
PLUMBING
BUSLIC
Business License
BUILDING
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