03060190 CCI'Y OF CUPER'fINO �'�' �+ r ` ° " �•
_ OUILDINCDIVISION PERMIT xCONTRAOTO, INFORMATION '
BUILDING ADDRESS: PARRY MARTIN H AND JENNIFE ERXDTNo03060190
OWNER'S NAME: PERMITISSUEDATE
PARRY
ONE: SANITARY N0. CONTROL NO.
ARCHITECtIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION
v I hereby affirm that I am licensed under orovisiuns or Chapter 9(commencing Job Descri�QtionyaA
�ti lP-'a
iE with Section 7000)of Division 3 of Ne Business and Professions Code.and my liters¢is In tl ss v'ss�l�
+�„ in muraaanderm" MAIN WATER LINE
7 Z License Class Lk.0
e Dare Contractor JUL ' 5 2003
ARCHITECTS DECLARATION
C ce t 1 understand my plans shall he used a public records
JuOU
apr^ Licensed Professional BUILDING
g OWNER-BUILDER DECLARATION
af I hereby affirm that I on exempt fru.the Cmamelc's License Law for the
00 following reason.(Section 7W 1.3.Business and Pmfecsiofu Cade:Any city or county
<m which requires a pomit to concoct,alter,improve,demolish,or repair any structure
°Zoi prior m it issuance,also sequins the applicant for such Permit o file a signed xummcm
i< that he is licensed pursuant to the provisions of the Comfacsur's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
[HO (commencing with Section 7WK))of Division 3 of the Business and Professions Code)or
$
that he is exempt therefrom and On basis for Nc alleged exemption.Any violation of 36624030 . 00
Section 7031.5 by any epplinnt for a Permit subjects the applicant to a civil penalty of APN Number Occu ane-Type
net mom Nan five hundred doll..(f50y). P Y YP
I,as owner of have propeny.or my employees with wages v their sole compensation,
will do the work.and the swctum is not intended or offered for sale(Sec.7(1 Business
and Professions Code:The Comsacto's License law dae not apply to an owner of 202 - UNDERFLOOR PLpCTMtB I NG
property who builds or i r,m es due...n,and whudoes such work himself or through his
awn employas,pm•ided that such improvemenu art not intended ororfued for We.If. .301 — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
builder will have son wmen of proving that lm did not wild or imp vie for parpese of 507 - FINAL PLUMBING
sale.).
❑1,as owner of the property,am exclusively contacting with licensed contractors to
concoct the project(Sec.7044,Business and Professions Cods:)TM Contractors Li
cove law docs not apply as an r of property who Wilds or improve thcmon,and.
whocamra for such projects acamnctor(s)heencdpursuanuo the Connector
LKCnY
0,an a our ec. .B&PCfbthisreasor,
O ncr t
ORK 'S COMPEATION D TION
1 hereby slam under nalty er peof rjuty one of Ne following declarations:
I have and will maintain a Cenificzm of Consent to Wir.insure for WorkersCompen-
ion,as Provided for by Section 3700 of In Labor Code,for Ne perfamnance of Ne
1371W
rk for which Nis permit is issued.
I have and will maintain Worker's Compensation Insurance,a required by Section
of he labN
or Code,far e Performance of the work for which Nis permit is issued.
Worker's Compensation Insurance carrier and Policy number am:
Polity
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
glosacction need not becompleed if nm probit is forove hundred dollars(g ITAs)
or less.)
I cenify Nat in the Performance of the work for which this Permit is issued.I shall not
employ any person in any manner so u in become subject to the WorkerCompensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:IC after making this Cenifcate of Exemption,you should
become subject to the Worker'a Compevation provisions or the Lavar Codt you most
.J z foMwith comply with such previsions Or this Permit shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
't•+ I herebywhich
tri Nm Nerc is a construction d(SO, Trading agency for the perfarmanrc of
C' Um court for which Nis permit is issued(Sec.3091,CO,C.)
W Lender'sName
z Add
4• I<ndcr's Address
U
IL O I ttfree Nat 1 Mare read his application and aura that rhe above cos rel aalun is
0 U coned I agate to comply with all city and county ordinances and sum laws relining e
U adevcngconnmrnon.and hobby auNonaereosesenmiw of Nis city memo upon Ne
F031 aWvemenuuned Pmpcny for inspection purpowhich m.
c. (We)agora w ave,indemnify and keep haomkess the City of Cupenino againsn
cl�z incobi itics.jvdgmcnu.cotes of
swhich may in any way save against said City
(„) z incon ,O G nnf of Nis(�ermin.
^ APPLICA t ULD RST DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR-E G L ION .
n aft of ApplicanUComncmr - reed— 6f- Re-roofs
HAZARDOUSM TERIALS DISCLOSURE, Type of Roof
Will the applicant or future buil ing occupant store or handle ha�ous material
CC defined It the Cup)Oino Municipal Code,Chapter 9.12,and the Health and Safety
trete,SceOan sa7(')7
Dye All roofs shall inspected nor to an roofingmaterial being installed.e
Will the applicant or futurebuilding
Occupant use equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
it Mrufdne air emmxrmro.uu mod by tM Bay Arca Air Quality Management all new materials for inspection.
evI
ct'
❑Yes
IMvere the Mmdsm.s materials mqulremrn.under Chapter 6.95oftheCali pro,
1�qturc
HealN&S� tCode,Sccd 5505.2533. n534,1unW.=dthmiOMWilding
rs no,core ly ve a an at it is my reeponsi hility m n the scup.,of Nr
mcnu hiest me non.issuanceofaccnifcamof uppeSignature of ApplicantDa[e
rlumomedaver, Dam All roof coverings to be Class "B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. j�,All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
. 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (re a side .
Property Owner's Signatu >j fe: 67/2 f
job Address 166 IS" (42, UWIIAIJ Permit 1 66
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE o 3 ° 0
CIUCUPEI�TINO PERMIT APPLICATION FORM
APN# q" Date: &1311 03
Building Address: Ol y
Owner's Name: Phone#:
Nei A-) PAPKo r C 4a8 99& '2s 87
Contractor: HOAR tN Pho : License#:
Contact: Phone: Cupertino Business License#:
Buil ' g t Info:
Id g Elect ❑ lum
Job Des tion: p,<"ct: S7�t_ Wo—,El,;, SSP _ F(�M ItigtAl �✓,7,-e lZt�
mo of HOUSE
Residential Commercial ❑
Cost of Project: yt S (P/P£ / O 61 iiINGS On L�,
Qty. if
A a Fee ID Fee Description Fee Group
PPERMITFEE —PlumbingPermit Issuance PLUMBING
j3-=PIPE 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
-2,
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