04060056 CITY OF CUPERTINO x 7+- -
BUILDING DIVISION PERMIT CONTRA.G'1�4R'INT+'C7, It1 .T,( N, -
Btu],
LDING ADDRESS: DIJOSEPH' S PLUMBING 1E1MfTN0.04060056
105
OW NER'S NAME: PERMIT I55UEDATE
DIANA PETERSON 205 WYAND
NE: SANITARY NO. CONTROL NO.
(408) 365-2058
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
wi
im I hereby MI.that 1 am licensed under provisions of Chapter 9(commencing p
n<
with Section
rez n�u�ss f Diviuon3of the and ofcasio
nx CSoend mylic)cnu is
I.full forte unit c"' / Lie. SCr
ClREPIPE
Lim
Data Contractor
ARCHITECI'SDEC RATI N /
/ 1
/91in derarand my plans shall he used as public records
aU
T Licensed Professional
�
Q 3 OWNER-BUILDER DECLARATION
4<� Thereby affirm that I am exempt from the Contractor',License Lew for the
E n O fallowing mason.(Section 7031.5,Business and Professions Code:Any city or county
0$ which Omahas,a Permit to construct,alter,improm,demolish,or repair dray structure
g�y prior In its issuance.also hequlRslhe applicant for such Permit to file a signed stacounit
that W is licensed pursuant to the provisions of the CanV¢mr's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
d (commencing with Sudan 7000)of Division 3 or Me Business and Promisinns Code)or
y $ that he Is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty ofaDC'"ex 0 0 OGGII 1y,
not mom than five hundred dollars(5500). Occupancy Type
❑I,m owner ante pmperty,m my employees with wage u their sole compenud.n,
will de,the wad,and theavuctum is not intended oro0emd patients(Sec.7014,Business
,and Profeuiom Code:The Contractors License Law docs nm apply to an owner of Required Inspections
property,who bui Ida or i m proves thereon,a nd who does such work himself or through his
own employees,provided thatauch Improvements arc notintended aro@red forsake.IL
however,the building or improvement is old within one year of in mpledon.Ne owner.
builder will have Ne burden of proving Net he did not build or improve for purpose of
at.I.
❑1,as owner of the prop thy,am exclusively contracting with licensed contractors in
construct the project(Sec.7044,Business and Proficia ans Case:)The Contractor's Li.
ecru.Law does net apply to an owner,of property who build.m improves them..,and
who contracts for such projects with a conuaemr(s)licensed pursuant to tm Convectors
License Law.
❑l am eaempt under Sec. ,B&PC for this moon
Owmr Data
WORKER'S COMPENSATION DECLARATION
1 heroby a0wm under penally of perjury one of the following decimations:
1 haw and will maintain a Ceas
um
ote ofConto self-insure for Workers Compen-
afltion,u providc0 for by Section 7700 of the labor Code,for the performance of the
work for which this permit is issued.
haw and will maintain Wmker's Compensation Insurance,as required by Section
3700 of the Labor Code,for tm performanec of the work:for which this permit is issued.
My Worker Comfremation ins race cartim end Policy
''number
��am��:������
Carrier: r0;, 1v1''rj �k� Policy N..:A�f(
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Nis section nmd not heeompleted If the permit is for one hundred totters(SIM)
or less)
1 certify that in the performance of Ne work for which this permit is issued,I shall not
employ any person in try manner an u to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.sitar making thi,Certificate of Exemption,you should
become subject to Ne Waders Compensation provisions of Ne Lehr Cade,you must
O mohwith comply with such provision or this permit shall m ramrod remium.
Z M CONSTRUCTION LENDING AGENCY
[—i Ihereby aM.that there is ammnxtinn lending agency nor the Performance of
the ward(m which this permit i.lutist(Sec.3097,Civ.Cd
W Q Lendcr's Name
D
�Z Censers Aeerma
V Q I certify that 1 haw mad this application and sure Net the above information is
IA P come,.I agmen to comply with all city and county ordinances and slow laws relining to
O Vbuilding convection,and hereby authmice representatives or this city to enter upon the
�
fig above-mentioned!prsPeny for and
arab rsesrar purpose..
(„i d
(we)agree to save,indemnify and keep harmless the City of Cupertino against
y inconsequence fMecostsand expemcemit. may in envy way scent.against said City
C)'z APLICANT of Me granting of this Permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da e
g.yOU�R RE CATIONS.��/(• i
�' 14 Oi, /,�e��^ �' 7'ay Re-roofs
Sign tom a Applil cam/Canuumr Doe
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant art future building necupmt store or handl.hazardous mammal
u d 1ned by the Cupertino Municipal Code.Chapter 9.12.ere the Health and Safety
rule.Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or future building occupant tau equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
1,ha'rarmme air contaminants as dcOned by Ne Bay Area Air Quality Management all new materials for inspection.
7-ia
❑Yes OR.
I have mail the huardouamawriab requirements underChapmr6.95 ofthe Califor-
Health&SafetyCodaSce ans 25505,25533 am125534.1mme mod that ift e building
r not currently how a mount,that it u my responsibility to nodly Ne mcupml of the
mnmcnu hmhmastbe CI rtwissaame.raCertraa oracupancg Signature of Applicant Date
I Ioray� ^?^a
Owner ser amhanzed agent "t Dam All roof coverings to be Class "B" or better
r
CITY OF CUPERTINO -�
REPIPE/SEWERS/MAINSERVICE
CUPEIZTINO PERMIT APPLICATION FORM
APN # 36 ,7- � 3 — 0,2 2 ` r
Building Address: 10 �� 3 ry Lo `O _Au
/
Owner's Name: j ll nq re Jr;oli a/ Phone#Z 5^ 7 a
Contractor:/fir )/�s S / Phone: 2� r� r P� License#: V 911 o/+ (�
Contact: rj / �r " OS hone: 2/6 �7�2os,D Cupertino Business ILicense#:
Building Permit into: / Q
-Bldg ❑ Elect ❑ Plumb C
Job Description:
Residential Commercial ❑
I
i
Cost of Project: i
• o0 4
Qt . if
Ap6licle Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING I
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