05010050 CITY OF CUPERTINO �'% ✓a -t*Ss; �' /`<' ='
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: ALLSTAR PLUMBING PERMITNOOSOlOOSO
n?nl GARDEN MANOR 2T
OW NER'S NAME: PERMIT ISSUE DATE
,ONE: SANITARYNQ CONTROLNO.
(408) 251 -6040
RCHITE-CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELELTIPITPMECH
L� 0
±oo LICENSED CONTRACTOR'S DECLARATION
w❑ 1 hereby affirm that 1 am lice under p[ovJ'^ rcha i 9 anmmeneeg Job Description
FZW with cion. y of Division 3 of M.wmrcxr aplbufeesi ms Cudc,and mylicrome,
mu` ander�t. 2� // D3161' REPIPE/WATER HEATER .
dqg Lig lass Lic.R
r❑ Date
ContractorL /
ARCHtheuse DECLARATION /
¢ I undcratxpywty plans shall lc used as puMievrtm nds 3
>yU
a O Licensed Pn'fcstional
S OWNER-BUILDER DECLARATION lJ
a4 1 hereby affirm that I am exempt from the Contractor's License Law for the
a o follnwing reason.(Section 9031.5.Business and Professions Code:Any city or county
m which requires a pem'ii in construct,alter,improve,demolixh,or repair any simulate
as
Prim to its issuance,alsosequires the applicant forsuch Permit it)fileasipned statement
_nt that he is licensed pursuanuothe provisions oftheContractor'sLicense Law(Chapmr9 Sq. Ft. Floor Area Valuation
Zi—$ (cummcncingwith Scction0000)of Division 3 oflhe Businessand Profession Code)m
— that he is exempt function,and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 9XNG,f1iMgr0 0 OccupancyType
not mom than fivn hundred dollars($5M),
YP
1,as owner of thc property,Or my employees with wages as their mm compensation,
will do the wind,,and the auuclum is not intended or offend for sake(Sec.1061.Business
and Professions Code:The Contractors License,Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,Ne building or improvement is sold within one year of completion.Ne owner.
builder will have the W rden of proving Nat he did not Wild or improve for purpose of
salt.).
❑1,as owner of the proven,,am exclusively conning with licensed Comments 10
construct he project(See.70u14.Business and Professions Code:)The Connactori Li.
cense Law does not apply to an owner of propeny who Wilds or improves themon,and.
who contracts for such projects with a contractor(a)licensed pursuant o the Conuador's
Lit a.Law.
I am exempt under Sec. .B h P C for this mason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declicalk nin
1 have and will maintain a Certificate of Consent to self-inaum for Workeri Compen-
tion,u provided for by Smian 3900 M the Labor Code.for the perfm rmaec of dm
work for which Nis permit is issued.
0 1 have and will maintain Wurkcr'a Compensation Insurance,as acquired by Section
3)IXl of the Labor Codc.for the Performance of Ne work for which this permit is issued.
My Wor: s mensation11 Insurance carder and Policy furorsN, wt
I
er'.
Po1iCy No.: N 1`f
CERTIFICATE OF E%EMPnON FR ERS'
COMPENSATION INS A -
(Thia secsinn necd'wt xcmmrlemd i(tx I'emtit is rat one M1undmtl dollars(g1IXB
or less.) ,
1 ccnifv that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner an as to become subject to the Worlaca Comptnsatiun
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Centipede of Exemption,you should
become subject to the Worker Compensation previsions or the labor Code,you mum ,
� O forthwith comply with such provisions or this Permit shall W deemed invoked.
Z CONSTRUCTION LENDING AGENCY
I xreby affirm eat them is a co m mution lending agency for the performance of
Z 7 the work for which this pcmnil is omaud(Site.3097,Civ.C.)
't1 p Lendcr's Name
Unders Address
Z
J O 1 certify that 1 have read this application and sem Nat Nit above information is
y H correct I agree to comply with all city and county oNinances and tome laws retiring to
Z) U building coemaction,and hereby molumire mpmmMidivea of this City to enter upon the
Jw C above-mentioned intercity for inspection purposes.
(We)age save,i mmfy and trey harmless the City of Cupertino against
;j h liabililies,judgmc ts, oats d pensee wM1icM1 may in any way acme againa said City
Inco uence of a n'i a this Permit.
APP A UN ER TA AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale /
SOUR RE LA S.
_ Re-roofs
'Si arc ApP"aH ZARDOUSMATERIALSDISCLOSURE tor Dat` Type of Roof
Will Nit applicant or future building occurrent atmc fir handle connector material
as defied by the Cupertino M cipal,Code.Chapter 9.12,and the Health and Safety
talc.S ms 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑tea u
Will thea applicant fir III tore building«eu ant a.e e If a roof is installed without first obtaining an inspection,I agree to remove
pp6 p yvirmcm or devices which
it M1amm�us air conmmina as defined by the Bay Arca Air Quality Management all new materials for inspection.
c9
❑Yca NO
Ihavcm the by N' smaterials myuimments under Chapmrd95ofthc Califnr.
ria He 'Self ty o'Ic, d 25X15,25531 anal 25536.1 undcraand Naif the Wilding
does t as it u my respnibility to notify the no union Or Nit
myai in maw eh sax I, Iismianeenr. ani eampr(ogcc/wwJa��cr' Signature of Applicant Date
ow6min tthmixe gens D,te - All roof coverings to be Class "B"or better
S1030Community Development
0
0Torre Avenue
O
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS:
-2,0701 �/9i/�G�yC M,09 wO e P IT # G�
OWNER'S NAME: -16'/1/1 e t PHONE # Q
GENERAL CONTRACTOR 1/ FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 fi 2
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T•
OV
Owner/Contractor Signature Date
CITY OF CUPERTINO o aSU
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # Date: 7.04/
Building Address:
zo-?oi 6191wt-O A4,ww6k2 O-�
Owner's Name:_ / Phone #:
J� M(466Ec T 40S) T>3 - 00 ?�
Contractor: Phone: License #:
Contact: ` f Phone: Cupertino Business License #:
eye 11491-9 4W? Y6z -to 66!5,- 7�Z6ii
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
ResidentialCommercial ❑
Cost of Project:
a�0
Qty. if
A li e Fee ID Fee Description Fee Group
PERMITFEE Plumbing Permit Issuance PLUMBING
PREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS V CS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
B LIC Business License BUILDING