03070193 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION b
TRS
BUILDING ADDRESS: KARAM /GERGES PERN003070193
OWNER'S NAME: 10376 JUDY AVE PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECI'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
10 0 LICENSED CONTRACTOR DECLARATION -
Iw 1 hereby affirm that I am licamed under provisions M Chapter 9(commencing Job Description
<0, with Section 7IX0)o1Division 3o7the Business and Prufecsiosn Cadl:.inl my Its,.is
i imnmmas errLLl._ REPLACE WATER SERIVE i"�
— Liccnu Class Lic.11 Imt-a
]�W DatC Cuntrdcbr
ZZ ARCHITECTS DECLARATION ']
K' I apdLrSund my plana shall he used as public records J U L 2 9 20 03
51U
r � Licensed Professional
so
COWNER-BUILDER DECLARATION p�(_
a S 1 hereby affirm that I am exempt front the Contractor's License Law for the BUILDING
po following mason.(Section T01.5.Business and Pmfcsxm ions Code:Any city county
m which requires a permit sea construct,alter,improve,demolish,in repair any suuctum
_iy poor o its issuance,also requires the applicant for such permit to rile a signed Statement 300
SEC that he is licensed pursuant to the previsions(if the Contractor'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
et— e
(comm ncing with Section 7008)of Division 3 of the B usinvs and Pmfecsions Codo)or
y $ that he is exempt Ihemffom and she basis for the alleged exemption.Any violation of 37510005 . 00
Section?031.5 by any applicant for a Permit ubjects the applicant o a civil penalty of ApN Number
not mare than fin hundred dollars($500). Occupancy Type
1,o owner of the property,army employees with wages as their sole compensation,
WL a the work,and die swcmrt is net intended oroRrmd for ala(See 7044,Business
and Professions Cade:The Coma or's License taw docs not apply to an owner of Ke ections
proprnywho builds or improves thereon,and who doessuch work himselfarthtough his 202 — UNDERFLOOR IR MBING
Own employcee.provided that uch improvements are notintendedoroffefed forsale.If. 301 — ROUGH PLUMBING
however,the building or improvement is said within ale year of completion.the Owner
builder will have the burden of proving that he did not Wild or improve for purpose of 302 — TUB & OR SHOWER
sale.).
❑ I.as owner of the proxxrr.amexclusively contracting with licensed contractors to 502 — FINAL PLUMBING ENERGY
consumer the project(See7844.Business and Professions Code?The Contractor's Li 506 — GAS TEST
corse law docs not apply to an owner of property who Wilds or improves themon.and, 507 — FINAL PLUMBING
who contracts for such pvects jwith a conueetor(s)licensed pursuant to she Contractor's
License Law.
❑ 1 J- .R.6�1
rSee. ,B k P C for Nis moon
Own .) Date S((COMPENSATION DECLARATION
m under penalty of perjury am of she following declarations:
1 have and will maintain a CrniOcnte of Covent to Self-ivum for WorkeriCompcn-
tion,as provided far by Section 37M of the labor Code,for Ile perfafmanee of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compeasnion Insurance,o mquimd by Section
3700 of the labor Code,for the performance of the work far which this permit is issued
My Workers Compensation Instance carrier and Policy number art:
Cartier. Pit icy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplacd if the permit is for sac hundred dollars(Stall)
or Less.)
1 comfy Nal in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner So as Or become subject o the Workers Comprnsation '
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this cci i0cate of Exemption,you should
become subject to she Worker's Compensation previsions of the labor Code,you muss
.J O forthwith comply with such provisions or Nis permit shall the deemed revoked.
'Z y CONSTRUCTION LENDING AGENCY
[-+ Ibotchy Orion that there is a construction lending agency for the performance of
C' the work fur which this proal is issued(Sec.3007,Civ,C.)
CQ Under's Name
2 Under's Address
U O 1 certify Nn 1 have rwd this applicalion sad state Nat the above Wollaston is
Hcared.I agree to comply with all city and county ordinances and state laws orating to
OU Wilding construction,and hereby authofre mprcantalives of this city to enter upon the
abbVC-mC judgments.
d Propertynt(OfdRefectionexpenses
pur,which may
F O. (Wc)agree to ave,indemnify and keep harmless the City of Cupnino against
p3 1.ca dies,judgments.costs and rspnros which may in any way accrue against aid City
U,Z� InLanYaemCCofthCgmnl oIIhISpGrmll.
APPL�A UNOERLATIO AN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
�Lq�` Re-roofs
nal canVCOnouctor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant start or handle hxax dour material
as dertnod by the Cupeninn Municipal,Code,Chapter 9.12,and the Health and Safety
Cale,SO Yes 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
❑secs �Nu
Will the applicant or future building occupant usecquipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ilharardnus air content",nanuyJcfncd by lite Bay Arca Air Qualify Management all new materials for inspection.
ouict7 �'kfN/I/,'t
❑Yes
1 have reel the harardnus materials requirements under Charier 6,95 of the Cali for
ria Hcalth6S oty CWc,Secduns255(15,25533and25534.1undcrsuMNuifthe Wilding
dos t cu ndy h nanl,Nal it is my responsibiliiym nndly the mcupant of thc
mqu tchmuaLhe mprionnissuarlcoofa Cembcacof Cecupan .
(y��� Signature of Applicant Date
aumadacd age D,te All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone#:
�- v- S
Contractor: hone: License#:
C4-" r-
Contact: Phone: Cupertino Business License#:
, tet Cs{ v S C� - 25- US/
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: /
G ,,L- '
Residential Commercial ❑
Cost of Project:
42(5-)o
G.
Qty. if
A li ble Fee ID Fee Description Fee Gr up
NCJ PPERMrrFEE Plumbing Permit Issuance PLUMBING
BPREPIPE 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