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04030037CITY OF CUPERTINO 7IIIYEQRMATION BUILDING DIVISION PERMIT BUILDINGADDRESS: CHAMPION PLUMBING PERMIT No. 04030037 OW NER's NAME: PERMIT ISSUE DATE ST ONE: SANITARY O OL NO. ARCHI7ECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH EQ LICENSED CONTRACTOR'S DECLARATION Job Description p 1 bEconomisty Or". Nal I on Econunder provision of Chapmr 9 (commencing with Section 70(10) of Division] of Ne Buse. Profession Code. and my lkenw u I1& a brmu, a Lrceµ�(.-94 3& Lieenx CS ` Lk: � PROP. LINE CLEANOUT emLEM Dow Cont cwr ��(_�(' C ATION MAR 0 g 2004 �eI �. and Is�1e1BI=SD ouchods pa BUILDING Licef ion OWNER -BUILDER DECLARATION al l am exempt frum the Conuaofs License Law for Me hereby affirm Ntt Oe/ eY{� following mann. (section 71131.5, Business and PtofesNon COde: Any city or county which .quires a permit ro ciamem,5, alter, improve, demolish, or repair any amelum prior. its iuuanec. also rcquiset the applicant for such permit. Glc a signed statement Ft. Floor Area Valuati e provisions Of Ne Contractor's Licence Law 9 that he is licensed pursuant to Li tt Sq. on (commencing with Section 71100) of Division 3 of the Busineas and Professions Code) or Nat he i5 exempt there0om and de basis far the alleged eumption. Any violation of 3 - 9tM*(zr0 0 Occupancy Type Section 7031.5 by any applicant for a permit aubjeets Ne applicant to a civil penally of not more Nan five hundred dollars (S500} I, a ownu of the pubpuSY• m mY employees with wages a Ne'v sole campertsstion, Required Inspections will do the work. and Ne structure is not immreded MoRcmd forage (Sce.7(ul Business said Prafeuima Code: The Combacmrs Li.. law docs aoI apply Nan owner of publicity who buildsorimproves theman.and whodansuch workhimself orthrough his own employees, provided Nm such improvements arc not intended oroRerW formic. If. however. Ne building or improvement is sold within one year of completion. Ne owner. builder will have the burden of proving Nat he did not bold or improve for purpme of sale.). 0 I, u owner, of the property am exclusively contracting wit licened contractors b construct Ne project (Sec. 706., Business and Professions Cade:) 77e Contractors Li- nse law docs not apply . an owner or property who builds or improves themon. and who contracts for such prejecu with a conamen ra) licensed pursuant. the Contractors License law. 0 1 am exempt under sec. . B & P C for Nis reason Owhe, Dale WORKER'S COMPENSATION DECLARATION 1 hereby affirm under peralty, Of perjury one of the following declaration: I have and will maintain a Ccrtiricam of Consent to aelf-insure for WorkersCompcn- sation. as provided for by Seeion 3700 of Ne labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain Worker' Compensation Insurmen, ax required by Section 3700 of Ne tabor Code, for Ne performance Of the work for which this permit is issued. My Workers Compensation Inurvlce caries and Policy number arc: Carrier. Z Polity Nom il' 7R7 3 5 3c7 CERTIFICATE NFR ORKERS' CERTIFlC OMPENSATIONI COMPENSATION INSURANCE Cron section need not be complced ifthe permit is forom hundred dollars ($] W) or less.) 1 certify Nat in the arrormanc, of the work for which this permit is issued. I shall not employ any permOn in any manner an a at become subject to NC Worker3 CUmpeIWtion Laws of California. Dat, Applicant NOTICE TO APPLICANT: If. afmr making this Certificam of Exemption, you should become subject ro Ne Worker's Compcnation provisions of the Labor Cook. you must forthwith comply with such provisions or this permit shell W deemed mvoked. CONSTRUCTION LENDING AGENCY thi Nat Vert is acd(Sm. i3 leading agency for Ne perfurmance of Ihorw which Mae work for which Ihii pernil is issued (Sm. ]097. CIV. C.) Landers Names ` 1<maerS Andrea . 1 certify that I have mad this application and stale that Ne above information is cone,. 1 agree to comply with all city and county oNinances and sale laws refiling . building construction, and hereby sulhorine mpracr atises of this city in cuter upon Ne above-mentioned preperty for inspection purposes. (We) agree to save, indemnify and keep harmless 0e City of Cupertino against j Iiabilhiujudgmcnu. Cosa and expenses which may in any way accfue agaiost said City in coneegobncc of the granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date SOURG Re -roofs Type of Roof 'LATIONS. O�O Oa/ Y sig A nca HAZARDOUS MATERIALSDISCLOSURE a. Will de applicant or future building Occupant store or handle havarEous material as scribed by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety cMae. sectionu532(a)7 ` All roofs shall be inspected prior to any roofing material being installed. 0Ya (No If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant use equipment or devices which it havardm a air Continuous as dnfimed by the Bay Area Air Quality Management all new materials for inspection. Diarict7 0 Yes [ 1hatsresd NeMmnu5m=c alsrequimmenuundefChapmr6.95orlheCaliror- nialkallh&safctyCe.Sa6wr25505,25533and25536.lundemand Nmirthc Wilding dao mol c oily have a vmant Out it k my mapons,". y tify the occupant of Us require nawiF por narcor.Certi �� `i/ Signature of Applicant Date All roof coverings to be Class "B" or better own, alhoriped igen Dale Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 CITY OF Fax (408) 777-3333 �UPEI�TINO Building Department JOB ADDRESS:>4 9 Y8 ��2,v �� PERMIT # OWNER'S NAME`"V IPHONE# GENERAL CONTRACTOR IFAX# I am not using any subcontractors: Signature Date Please check applicable subcontractors and cmmnlPtP +hP fnllnwina inf,,,•. n#4, „• 60 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 Owner/ Contractor Signature d�o�Coc! -Q Date 0 is qW CITY OF CUPEkTINO CITY OF CUPERTINO � 7 0 3 ° e,."3 REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM APN #3 ?� 3 � O � 4 Date: 03O Building Address: BPREPIPE Owner's Name: Phone #: Contractor: Phone: License #: Contact: Phone: L� .3 5�v7�2ovl��S C9� Cupertino Business License #: Building Permit Info: PLUMBING Bldg ❑ Elect ❑ Plumber Main Water Service Job Description: BPSEWER Residential A5 Commercial ❑ PLUMBING Cost of Project: ) Sewage Disposal Qty )l App cable! Fee ID Fee Descrintion Fee Grnun PPERMTTFEE 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 v�7 Uzi 7. 66