05080220 - CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAGNOR�INFORMATION.
BUILDING ADDRESS: BAY AREA REPIPES PERMIT NO.o S O 80220
-10311/10321 GR
OWNER'S NAME: PERMIT ISSUE DATE
Alk CUPERTINO COMMUNITY SERVICE 1861 ORANGE GROVE DR19 0 24 2005
NE:
SANITARY N0. CONTROL N0.
(408) 371-5763
ARCHITET/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i O z LICENSED CONTRACTOR'S DECLARATION Job Description
w FO 1 hereby affirm flog I am licensed under provisions of Collator 9(commencing P
�ity with Section]q)ll)af Divisi Jof NC Busirmm vrd Prafcssiom Cod/e,and myliccnse is
^bra in full force andcfR ir N . REPIPE ENTIRE BUILD/WATER SERVICE
D,RE Licenu Claza (� 1O Lic.p
�r-O Dam A 7. �Contractor (4 UNITS) '_l�f/
TTGo ZY<y(RCHrtECPS
DEC
f Cy'k '
I understand my plan shall he used a puhlic rceaiJ �G. Lisp
vr.
.
Iu
a, Licensed Professional
OWNER-BUILDER DECLARATION 1Mi7 D/ 2QO[
<P 1 hereby alfrm that I am exempt from the Contractor's License Law for the SS�- J
HO following mason.(Section 703[.5,Business and Professions Code:Any city or county
which requires a permit w canSIMCl,alter,improve,demolish,or repair any structure
a¢iprior ser its issuance.also mquims the applicant for such permit to Gla aligned smmmerd 1 ,y
s< that he is license)Puri a.the rovisions of Ne Comraclur's License Law(Chapter 9 Sq.Ft. Floor Area t "$9 Val -gibDro O0
yhn (commencing with Scdian]000)ofDivisionJnf the Business and ProfessmnsCak)or }1 L ��
i $
Out Ire is exempt mcmfman and the basis far the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(S500). 36914025 . 00
❑has owner of the propcry,or my employees with wages as their sole eompenaddon,
will do the work,and the swctom is not intended matured for sale(Sec.7014,Business
and Professions Code:The Contactors License Law does not apply to an owner of Required Inspections
property who buildsorimproves thereon,and who does such warkhimself orthrough his
Own employees,provided that such improvements are not intended or offered for ale.If,
however.Ne building or improvement is sold within mm year of completion,the owner-
builder will have the Worm of proving Nat be did not Wild or improve for purpase of
sale.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
emuhua the project(Sec.7044.Business and Professions Cade:)The Contractor's Li-
cense law docs not apply to an owner of property who Wilds or improves daemon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this reason
137"W
ner Date
WORKER'S COMPENSATION DECLARATION
1 hereby al inn under penalty of perjury one of me following declarations:
1 have and will maintain a Certificate of Collum to self-insure for WorkefsCrmpen-
ian,az provided for by Section 3700 of the labor Cods,for the pcffosmance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,az rryuined by Semon
of the labor Codd,far the performance of the work for which this permit is isihd.
WarkcrG's p1pasation linitisate carrier and Policy number am: ,V/L]/J 1 Me. Policy Na.: 7'7oCERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W complemd if the permit is furore hundred dollars(SI W)
nr Iris.)
1 canlh Nat in the perfmmance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:if,after making this Cenifieasc of Exemption,you should
became subject to the Worker's Compensation provisions of the Labor Code,you must
.J O foMwida comply with such previsions or this permit shall W deemed evoked.
z CONSTRUCTION LENDING AGENCY
[r4 I hereby affam Nat there is a construction lending agency for the performance of
C> the work fur which mis permit is issued(Sec.3097,Civ.C.)
I[]Q Lender's Name
a Lender's Addmss
UQ I certify that I have read this application and sum Nat the above information is
LL F' comacL 1 agree to comply with all city and county ordinsnces and state laws relating to
0 C.) building construction.and hereby Andunno mpresentmisv of this city to enter upon Be
Y'4 above-mentioned pmperly for inspection purposes.
(We).,me w save,indemnify and keep harmless the City of Cupertino against
.t".,h Iiabilides,judgrecns,emor andcx,re.,which may in anywayacc=againslsaid City
U Z in consequence of me grant of this perm it.
^t APPLICANT U T DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date _ 2 2_4r-
SUM UA
gn
2 f"Z elo-S Re-roofs
S4��
Sim od(AppTicant/Cbmfacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm Wilding Occupant store or handle helardous material
az dcGned by tW Caperton Municipal Code.Chapter 9.12,and the Health and Safety
Code,semen 25532(an
❑Yes ❑N All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or fume building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havafdous air contaminants a defined by the Bay Arca Air Quality Management all new materials for insp tion.
District?
❑Yes ON.
Ihave rtad NchmaNnuxmamrials roquircmcnu under Chapter the Cal //
ria Health&Safety Code,Sections N15.25533 am125534.1 understand ththatifaziflW Wildi n PS
docs not nxnllyham a Wntn at it is my rcspoasihilily to nodly the cupant of the — - — - �t'x' J
roqui m to A;rmissuanceof.CcrdfcamotOcapancy. Sign re ofApplican Dat
All roof coverings to be Class "B"or better
4 Own or authoriacd agent--�" Dam
Community Development
10300 Torre Avenue
^- Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPE(�TINO
Building Department
JOB ADDRESS: / PERMIT #
6 " /l e1632- / Gr-lcn tuotj z �. % 1 0 S-Od'o1z2)
OWNER'S NAME: Gt erj;h� f V i e--e PHONE # / J- 26 1
GENERAL CONTRA OR: Hca I eS FAX #
I am not using any subcontractors:
1 , ;2voS—
ature 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
7 � —
Owner/ ontra ttmSii ature Date
CITY OF CUPERTINO
CITY51-1REPIPE/SEVERS/1VIAIN SERVICE Z
OF
CUPERTINO PERMIT APPLICATION FORM
APN # o zS Date:n�l ZY yov�
Building Address:
0 / b 3 Zl rPC
Owner's N me: / Phone#:
�� 2( . .Alm QAik 51\1 c -p
Contr tor: J Phone: License
Conact: Phone: pertino Business License #:
0� wut�5�. , / S76 3 7- 3 y
Building Permit Info: /
BldgEl Elect El Plumb V
Job Description
-
p cG I n G / Qr✓� 4f
Residential Commercial
Cost of Proje
IS' vote
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
2 BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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