05120034 CITY OF CUPERTINO n
BUILDING DIVISION PERMIT zCONTRACTOR INF�ORMATIO.N ,�,
BUILDING ADDRESS: DAVID & BARBARA KOPELS PERMIT1,10-05120034
670 HALE PL DUPLEX
0.'S NAME: PERMIT ISSUE DATE
DAVID & BARBARA KOPELS 12/08/2005
E: SANITARY NO. CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO'
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTORS DECLARATION JobDescrip[`I®rto
w❑ I herby affirm that 1 Am licensed under previsions of Chapter 9(commencing
ZW with SCNom7")ofDivision 3afNe Business and Professions Code.and my license is lit-rrl A
« in full fame andeffem REPLACE WATER LINE (METER TO IHOUSS
j i Do. Class Lic.g
FO nC.MrSDECLARATION'J` v ARCHITECTS
� 1 undcrsuM my plans shall he used AS Public rtmrds
c u qa�q/J�Y17S14y�
t u. Licensed Professional ® ZD
O3 OWNER-BUILDER DECLARATION
OS
.�00 I hereby.(Sere Net I em cBmPl froman the Contractors Co :A License Law for the v
O O following mason. °ted 1 ?fD1.5.Business and Profcauuas h.A,Any oily or county pyysy�y fj
K m� which requires a permit m cnnswn,aline improve,demolLsh,or repair any stmctum (J`.y p'f $500
prior inits issuance.Alan requires the applicant for such Pcrmiuo 0lc axigncJ sin¢mem ppr
ESO Nat he is locnAud pursuanua Ne provisions of the Contractor's License law(Chapter9 Sq.Ft. Floor Area 4v#y Cy/ CIO❑
At l- (commencing with Section7")of Division 3nf the Business and Pimmeyas Code)Ur V
y R$ that he is exempt therefrom and the basis for the allcgedi cxempdon.Any violation of
Section 7031.5 by any applicant for a permit suhjcen Ne applicant to a civil penalty of r Occupancy Type
nor more than five hundred dollars(5500).
I,As owner of the prepeny,or my employees with wages as their sole compensation,
will do the work,and the sommute is not intended or offered for W.(See.7014,Business
and Professions Code:The Comment's Liam Law it=net apply to an owner of Required Inspections
pmpeny who builds or improves themon,and who docaan ch work himself orthmugh his
awn employees,provided Nat such improvements are not inendcd croffemad for ale.If,
he veveq Ne building or improvement is sold within ane year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
ak.).
I,as owrcr of the property,am exclusively contracting with licensed Contraction to
c mImom the Project(Sec.7064,Business and Professions Code:)The Canlractor's Li.
cease law does not apply to an owner of prope ry.who builds or improves themon,and,
who contracts for such projects with a eo ommor(s)licensed pursuant in Ne Conlncmrs
License law.
LQ_1 am exempt under Sec. B&P C(m this mason
r i'1 i4,y�f3�Dale/z �-mS -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of de following declarations:
I hs sae and will maintain a Certificate of Consent m AuIf OMM for Worker's Compen.
comm.a provided for by Section 3700 of the labor Code,for the performaxc of the
work for which this permit is tamed.
❑1 have and will maintain Workers Compenation Insurance,a required by Section
37M of the labor Code,for be performance of the work for which this permit is issued.
My Workers Campeasatim Insurance Carrier and Policy number art:
Cartier. Policy Nm.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
This Auction need not W completed tithe permit is foranc hundred dollars(SIM)
or ICss.)
I certify that in the performance of the work for which this permit is issued.I shall nm
employ any person in any mannerm as to bemmc subject to Ne Wcrkcos Compensation
Laws of Ci limmia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject in the Worker's Compensation previsions of the Labor CMB you most
.J z fonhwith comply with such provisions or this remit Shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
[••�• I hereby affirm that Nene its construction lending ageni,for the performance of
C the work(tar which this Permit is issued(Sec.3097,Co.C.)
(y Q Lender's Name
D+ Lenders Address
� z
U 0 1 modify that 1 have mad this application and sue that the about information is
Uy H torten.I agree to comply with all city and county ordinances and sum laws relating to
DU building ooneuuction,and hereby Mori¢MPresentatiscs of Nis city to enter upon the
>' above-mentioned properly for iospecdon purposes.
tC (We)agree to ave,indemnify and keep lum lass he City°(Cupertino against
fA liabilities,judgmcnta,costs and expenses which may in any way accrue Against said City
Z in consequence of do,firaming of
his permit.
U^' APPLICANT UNDERSTANDS IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU09EEGULI� ATION�S2 (�_g_�S
�yY`3`rRe-roofs
Signature of ADDI O° _tor HAZARDOUS MATERIALS DISCLOSURE Date of Roof
Will the applicant or future building occupant store or handle hammous material
Inia
fined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Sceima 25532(x)7 L.� All roofs shall be inspected nor to an roofingmaterial beim
❑Yea LINm P P Y being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hmardous air contaminants az defined by Nc Bay Arca Air Quality Management all new materials for inspection.
ict? f�❑Yes CJNo
1 have mail Ne haxardwari aerials requirements underChapler6.95 ofNe Califon
nith&SafetyCoA,Seetiona25A)5.25533 and 25534.1 understend thatifthe Wilding
not currently how a u nam,Nat it Is my MSFMA hility Io notify the occupant of the
mm whah v W eI wraaanceOra CertificaeofOccupanq. Signature of Applicant Date
lK /z s
Owner orauthorixed090KII Dale All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
\�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #0 Z a--->3d& 70 /�f< ec � -
OWNER'S NAME: L C PHONE #
GENERAL CONTRACTOR: ✓ 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
I .a
Owner/Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # 3 Z / // �/� Date:
Building Address:
Owner's uam` /✓mob Ka Z$ Phone#: g
ay,� �44 -
Contractor:
,C4 -Contractor: Phone: License #:
awn e-r goSC. 444-300 p'
Contact: Phone: Cupertino Business License #:
�-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb L*1�
Job Description: 1 9 r
[ /� h P S 'f y-cl . 5 cc�"/r��f'cL �c, 5 'l-' - ✓E�
Residential Corfintercial ❑
Cost of Project:
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
BPREPIPE Repi e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING