03100066 ITY OF CUPERTINO
BUILDING DIVISION PERMIT ;CONTRi1CbTORINFORMATION f
BUILDINGADDRESS: CUPERTINO PLUMBING 111111N'03100066
OWNER'S NAME: 10297 S DEI, ANZuA BLV PERMIT,SUE DATE
NE:
(408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECTENGINEER: BUILDING PERMIT INFO
BGDC ELECT PLUMB MEOCH
+00 LICENSED CONTRACTOR'S DECLARATION
�w❑ I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
?W with Section 70(kl)of Division 3 ofthe Business and Professions Code,and my license is
a in full force and cf( L
fig?
Liven
aaza �` Lich (n2-ySoS REPIPE/WATER HEATER p/ u
:I-w Dam Cumfactof C.TIO...O Y�Ia•� / (�/ 4lE/
fto ARCHITECT'S DECIARAt� y
f a U 1 understand my plans shall be used as public records O
r'0 Licensed Professional
OWNER-BUILDER DECLARATION
ja 8 1 hereby rtTrm that 13M exempt from the Contractor's License Law for the
o O following fcamn.(Section 703 L5.Business and Professions Calc:Any city or county
<m which requires a permit in construct,aret.improve.demolish,or repair any Stmaure
ptiorto its issuance,alsomquims the applicant forsuch permilm file axigned smtemem
That he is licensed a ti
oulto the r inis of the Contractor's License law(Cha heti) S Ft. Floor Area
LFC (commencing with Section 70001 Division 3 of the Business and Professions Code)or 9' Valuation
Nal he is exempt therefrom and Or basis for be alleged exemption.Any violation of 35931055 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of APN Number
nes an..Nan five hundred dollna(s51). - - -. Occupancy Type --_
❑I,az owner Of the phapcny,or my employees with wages az their sole compensation,
will do be work,and the structua is not intended or Offered for sale(Sec.7044,Business
and Professions Cade:The Comediennes License Law doss not apply to in owner of g PLp�eCtiOHS
properUN
property who builds or improves thereon,and who does such work himxlfor through his 202 - DERFLCJOR UMBING
ben empinyces.provided Nae such improvements are not intended or offered for=to.If. ,301 - ROUGH PLUMBING
however,the building or improvement is sold within one year of completion.be owner-
builder will have thr burden of proving Nal he did not wild of improve for purpose of 3 02 - TUB & OR SHOWER
sale.). 502 - FINAL PLUMBING ENERGY
T,as owner of the property.,B exclusively contracting with licensed trombone to
consrua the project(Sec.o a x,Business and Professions Code:)them Oemon. Li- S 06 - GAS TEST
me taw docs not apply a an owner of property who wilds a lmptovss Centro,ors 507 - F I NAL PLUMBING
License Lace for projects with a eonuanor(s)licensed pursuant m the Contractors
License Law.
❑1 am uempl under See. ,B&P C for his reazon
Own Data
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury m¢of the following declarniov:
1 have and will maintain n Cenificote of Consent to self-insure for Worker's Carolina-
7[3371W'�
on,as provided for by Section 371 of be labor Coda,for be performance of the _
h for which his permit is issued. "
I have and will maintain Worker's Compensation Insurance,a teyuired by Section
of the labor Code.for be performance of dr work for which this permit is issued.
Work es Compensation Insurance carrier and Policy number am:er.+ Policy No.:
CERTIFICATEOFEXEMPTIONFROMWORKERS' .. .
COMPENSATION INSURANCE
or less.)(This section need not be permit
completed if the is for one hundred dollars(S 100)
I certify that in the performance of the work for which On permit is houcd.'I shall nut
employ any person in any manners u to become subject o the workers Compensation
Laws of California.Date
Applicam
NOTICE TO APPLICANT:If,after making this Ceelfieahe of Exemption.you should
become subject t.the Worker's compensation previsions of the labor Code.you must
Oforthwith comply with such provisions or this permit ma!he deemed revoked.
ZCONSTRUCTION LENDING AGENCY
h
1 hereby which thi that there is a construction 3 lending agency Torr the performance or
0.x7
Under
nder a Na which this pertnit is issued(Scc.317.Civ.C.)
1 A lender's Name
D z Lender's Address
J Q 1 certify that 1 have reed thisapplication
and c un and sum Nat did awve information is -
y U corm.1 agree to comply with all city and county eminences and sox lama retying e
J C_) alhowngeoesuuctiroend for by maNctiorixrposesematives Of Nis city menmr upon the
CL awvc-(We)andare property for ire ni ry an purposes.
y (We)agmen to cove,indemnify and keep harmless the City or against against
N Eaconsquenc of ts,be ostsind of this eawbich may in any way secret against coil City /t
(J,Z in consequence of UNDERSTANDS
this permit l//
^ APPLICANT UNDERSTANDS AND /LCOJM1]pLY WITH ALL NON-POINT Issued by: Date
RGEitEOUCATR)F
7
SiOurtmeofAppiifor a a 3 Re-roofs
/
AF"OUs MATERIALS DISCLOSURE Dare Type of Roof
VST eapplicanum building wimpantsmre.,handle haisdrus hommal
az defined by the Cupeniro Municipal,Code,Chapter 9.12,and the Health and Safety
ode,Scnion 355J21a)?
❑ora All roofs shall be inspected prior to any roofing material being installed.
Will thea licam Or fwure building«err red use equipment If a roof is installed without first obtaining an inspection, I agree to remove
dip s p q it Qu or which g
ie hazardous air contaminenu az defined by tbe Bay Area Air Quality Management all new materials for inspection.
rsuict?
❑res Nu
How read Neha rdnusmawriakmquixmenuunder Chapter6.95 ofdhe Califor.
nia HcolO A Safely Code.ScmmO25505,25533 and M534.1 understand Not if the wilding
it(=not currently hast a heron,Nat it is my fespensinhuy to trimly IW O.cupor or be
reyuimmcnu which retro he o iss f a CcN emit of Dccupanry.
Id 9-oz Date
Date
owneraa ase DO. All roof coverings to be Class "B"or better
CITY OF CUPERTINOo 3 j ° 61c,
= OREPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# 6 Date:
/0 9—O
Building Address:
/ �ti oor L
Owner's Name: Phone#:
w " 140 2-5 -2-- 9�2
Contractor: , � 9vl�w 1 Phone: �G 1 g License#:
2!S -3-
_ G,-:Z C/5Pv_5
Contact: Y I hJ Phone: Cupertino Business License#:
raw
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 0�
Job Description:
Residential Co ercial ❑ J
I
Cost of Project:
• v ov
Qty. if
A licable Fee ID Fee Description Fee Group
PPERMITFEE —Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
w�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
�0'- -2, 3 �