05010111 CITY OF CUPERTINO -
BUILDING D[VISION - P>JRMIT 4' CONTRACTOWINF,ORMATION,
BUILDINGADDRESS: BELL PLUMBING SOUTH BAY PERMITNg5010111
OW NERR NAME: PERMR ISSUE DATE
-1710 YAT.F. WAY oi /ig/2no5
ONE: SANITARY NO. CONTROL NO.
279-8 24
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION
w I Mreby if,.that 1 am licensed under provisions of Chapter 9(commencing Job Description
Ii�' with section,my.foroiamn 3.r Ne Business and Professions cox.and mylicense is
moue Iaof errtt`' O INSTALL PROPERTY LINE C/O
icenu lea Lic.N
I he
qq ARCHITECTSDECLARATI
fX
3 I ,sand my plans shall be used as public records
JaV
O G Licensed Isteffacional
5 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the -
n O following mason.(Section 7031.5,Business and Professions Code:Any city to county
Sm which requires a permit to eonsnrcl,alter,improve,demolish,or repair any structure
¢i pdorto its issuance.also requires the applicant forsuch permitto fileasigncdsuemcnl -
< that he is licensed .ranammthe pmvi:mnsoflheCommet.r'.uns
cccLaw(Chaper9 Sq.Ft. Floor Area Valuation
��a( eomme acing with Section 7M)0)of Division or the Business and Professions Code)or
Thal he is exempt therefrom and due basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a penmil subjects the appllcan(m a civil penalty of ane 3 7FsHADN5t�3efl 0 Occupancy
not more than rose hundred dal lan(S5W). p y Type
❑I,as owner or she pecpeny,or my cmploycu with wages of Noir sole compensation,
will do the work,and the shuclum is not intended of fered for sale(See.7044,Business
and Prorassions Code:The Cnntrvctnr's License Law docs not apply to an owner of Required Inspections
property who foulest or improves thereon,and wh.docs such work himself.,through his
n employees,provided that such improvements are not intended or offered for sale.Ir,
however.Ne building or improvement is sold within one year of completion.the owner.
builder will have else Woken of proving that he did not build or improve for purpose of
sale.). a�
1.as wncr of he pmpcn,am exclusively...ow ling with licensed conmamm to /
construct the project(See.7864.Business and Professions Code)The Contractor's LF
cense Law docs not apply to an owner of properly who builds or improve themon.and Jv\
who smumcu for such projects with a eontrael.as)licensed pursuant o In Conlmatoi s
Lice Law.
aw.
C]e an Lacmpt unser Sec. .B h P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following dttlantioru:
L]1 hart and will maintain a Certificate of Corucu
no self-insure for Worker acompen-
salon,as provided for fy Section ITW of the labor Cada due e Performance or Ne
work for which this permit is issued.
have and will maintain Worker's Compensation Taxurantt.u required by Swion
J IID of Nc labor Code,for Ne performance of the work for which Nis permit is issued.
,y My Wark a Co., adon Insulane•carrier and Policy number art:
1//J Ganite olicy No.:
CERTIFICA F EXEMPTION FROM WS'
CO 1PENSATION INSURANCE
(This section need not he completed if IM permit is for one hundred dollars(gI W)
to less.)
I s eadfy Na in the performance of the wart for which this permit is issued.I sill not
employ any Pnm u any manner an to become subject m ftWorkers Compensation
Laws of California'Dem
Applicant
NOTICE TO APPLICANT:11.after making this Certificate or Exemption,you should
become subject m the Worker's Compensation provisions or the Iain Cie,you must
]z forthwith comply with such provisions or this permit shall M deemed revoked.
zO CONSTRUCTION LENDING AGENCY
1 hcmty shims that there is a construetinn Icndi ng agency In,the perfommec of
Y
the work for which this Permit is issued(See 3097,Civ.C.)
Y] Q lender's Name
Lenders Add.
� z
U Q I certify Nat I have read this application and slam Nal the above information is /
y F
cancer.I agree to comply with all city and county ordinances and stain laws relating a S
U building construction,and hereby amhmim representatives of this city to enter upon the
r ahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City or Cupertino against (��
rg liabilitie,judgments,costs and c.route which may in any way accmeagainst said City0 p _ s. 1 /'
J consequence.(IM graining or this permit. / UJ
A PLICANT U DER STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 RCE RE l+L N5.
J \ Re-roofs
Sig ore or ApPEcaHAZARDO Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or[.lure building occupant store or handle hasarduus material
as defined by the Curp niao Municipal,Code.Chapter 9.12.and the Health and Safety
Code,Section 355R(a)? All roofs shall be inspected prior to any roofing material being installed.
❑tics ON.
Will the applicanlor rutum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Im ardour air contaminants as defirsed by the Bay Arca Air Quality Management all new materials for inspection.
m
❑Yea ❑Nu
"an
mad the hasamous materials relmoconnts under Chapter b 95 or the Cold,
ria Health h Safely Code.Scedmn 25505.25377 and 35534.1 understand that if lM Wilding
does not eurmnay bac a cram,that it is my marroxi hiEty an Wiry the oceupml or Ne
whim vena etc mclpe.,m issuances.cerdrteamor ampmey, Signature of Applicant Date
owner.,authorized agent Dae 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
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
US o / O / //
OWNER'S NAME: ><1N PHONE # -510 -ta —telco3
GENERAL CONTRACTOR: , , , , FAX # �5 - 770-a37(-3-
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
Owner/Contractor Signature Date
d CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE oS' o f
CUPEkTINO PERMIT APPLICATION FORM
APN # -?75— ,.?
Building Address: IVJrC85 —5Oh A,fgt pr.) Py
Owner's Name: wN5/} Phone#:4Dp,-455-899-7
Contractor: eejl PL, VP4y Hyl Phone:w 0438 CW0 6 License #: o�O -7�-0'
Contact: 'SOAJ Phone:Lp(B (o�lto�a(� Cupertino Business License#:
Building Permit Info:
Bldg - ❑— Elect ❑ Plumb
Job Description:
lanc C( oJT
Residential WCommercial ❑
Cost of Project:
Qty. if
Appljle Fee ID Fee Description Fee Group
PPERMITFEE Plumbin.2 Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS V CS Main Water Service PLUMBING
m BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING