03080043 ' CI'T'Y O"CUPE21'INO
BUILDING DIVISION PERMIT U1CONTRACTQRjNF,ORMATION
BmLDINC ADDRESS: KEITH GARVINE PERMIT No03080043
20135 FOREST AV
OWNER'S NAME: 3077 ZION LANE PERMIT ISSUE DATE
CAMPBELL ROBERT W AND RACHEL C 08/11/2003
NE: (408) 259-7874 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION =1O O
m(= I hereby affirm that I am licensed under amviaons or chapter 9(commencing lob Description
u with Section 70110 of Division 3 of the Business and Professions Coda,and my license is
±� proBrameande .�_ 160K75� REPIPE & MAIN WATER .LINE
p�? Liccnx Clazs Lic.x ��N�LE®
,Fn Date 4'it•od Contractor MtJ u.o
3 ti ARCHITECTS DECLARATION '
1 a 1 undcatand my plans shall he used as public lecmds
Licensed Pndcssinnal
SEP 2 8 2003
in
OWNER BUILDER DECLARATION
p I hereby affirm that 1 am exempt from the Contractor's License Law for the �qs�
n o following reason.(Section 7031.5.Business and Professions Cade:Any city or county 041 B'B ®'wtl�
which requires a panni,m cnnsvun,alter,improve,demolish m repair any svucmre w ` ,tl 5000 OOO
�zvs priorm its issuance,alsorequlrea theapliicant f0rsuch permiuo file aligned su¢menl
-sa that he is licensed pursuant to be previsions of me Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
E s-� (commencing with Section 7000Jor Division J of the Business and Profeesinos Cotk)or
$ mat he is exempt Ocmfrom and dee basis ler the alleged exemption.Any violadnn of 31633070 . 00
Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of APN Number Occupancy Type
not more man five handled dollar.(S500). P Y YP
Q h is;owner of the pmpeny;m my employees with wages as their cele compensation.
will do the work,and the structom is not intended or offered for sale(Sec.7014,Business 30t - ROU
and Professions Codc:The Contractor's License Law docs not apply to an owner of 502 - FINAL ORGY
property who builds or improves themon,and who does such work himself or Omagh his
own employees,provided that such improvements Are not intended or offered for sale.If, 507 - FINAL PLUMBING
however.the building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
0 1.as owne,of be,property,am eaclmively eliminating win licensed convectors to
construct the project(Sec.7044,Business and Professions CWe:)The Contractor's Li-
cense Law docs not apply to an owner of property who Wilds or improves Ihemon,and
who contracts for such pmjecu with a eonmetof(a)licensed pursuant o the Contractors
License Law.
❑ 1 am exempt under Sec. ,B h P C for this reason
Own Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury as of me fallowing declarations: '
1 have and will maintain a Ccnifieete of Consent to self-insure for Worker's Compen-
sation,az provided for by Section 3700 of me tabor Code,for the pnfonnanec of the
work for which this Permit m issued.
1 have and will maintain Workers Compsmation Insurance,u required by Section
1700 or the Labor Codc,for the perfofmance of the work for which mis permit is issued.
My Worker's Cnmpemation Insurance carrier and Policy number am:
r ' Cnrticr. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section recd oat W completed if the permit is far one hundred dNlars(3100)
ar It..)
I certify Wal in Oc perfarnanec of the work for which this Permit is issued.1 shelf nut
employ any person in any manner,x azlum em bject to the Wofkcri Compensation
Lawes of Calif yD�e �JT�5's D3
APPlicant V=
NOTICE TO V to t ANT: rs opts making leis visions of of Exemption,you should
became authjea to the Worker's Compensation provisions of the lobar Code,you moa
z fanhwithcomply win sucM1 prnvisimna or this permit shall W deemed rtw,ked.
Z'O CONSTRUCTION LENDING AGENCY
PI heathy affirm chat there is a consvuctinn lending agency for the Performance of
C' the work fur which leis permit is issued(Sce,3097,Civ,C.)
LQ 0 Lender's Name
jz finder's Address
fJ Q 1 certify that 1 have read this application and auto that the above information is
U. f" comet.l agree to comply with all city and county ordinances and state laws relating to
Q U building constmetiun.and hereby authorise mprexnmtives of this city to enter upon the [ ,/7ry(/, /
� a
above.menudnedpmp asn tori expenses
pogwxs
(We)agree to save,indemnify and keep hanalcss the City of Cupertino against
F+Z in1-iues.juse q tthec strand ex this pe nil. may in any way accmc against.said City
Uz in consequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINr Issued by: Date
SOUB ATIONS _
11 O
c g a�1 canticontraetor < Date Re-roofs -
HAZARDOUSMATERIALSDISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle harardors material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safetyagn6kr
ak.Section 35532A)7
❑Vas No All roofs shall be inspected prior to any roofing material being installed.
Will the a licanl or future building occupant use If a roof is installed without first obtaining an inspection, I agree to remove
PP 6 p a Ail Qu or devices which g P
it harardnes air conleminanu u dcfncU by the Bay Arca Air Quality Management all new materials for inspection.
Dlalflfl? '
rMs o
Ihevcmed thehalarthum255l3larequian underdconan thatifdte Califon 1, `
nia Ai n t ane Ily Cndc.Sccdues 25L it is m r sod 355J4.I undersand r rex he Wilding / o
dms not cunt IIY hasn.>\nant,ma it it my responsibility m nodly tW rveupant of the
rcquimme hien a nftoissaen Beamoflxepn er. Signature of Applicant Date
03
owner aarhonaedageAl Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: �}
o� �e
Owner' Name: Phone#:
T'R-r � Irl c40�-
Contractor: Phone: License#:
PCc)roLk� qog ZS' -78' 7 0'8 751
Cont ct: Phone: Cupertino Business License#:
errmt Info:
Bldg Elect ❑ Plumb
Job e 'ption:
I ti47aIm4lm W w J i na
Residential Commercial ❑
Cost of Project:
Qty. if
A 1' a Fee ID Fee Description Fee Group
PPERMTI'FEE 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
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