05080259 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMR NO.05080259
�I R99, T TNr1V TJIT
OWNER'S NAME: PERMIT LSUE DATE
DAVID
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONIRACOR'S DECLARATION
e u C 1 ber:bffi
y arm u
he, am licensed Mcr pmvimmu of Chapter 9(commencing Job Description
!zue withSection 70710)of Division Sof NC Business and Professions Code,and my license is
0;„ infulloreeanticfjcca (� REPLACE WATER SYSTEM/REPIPE OF FIXTURES
jv�? Liccnu Clan (.1LTL c- Lica
�o
Data 151i1c Contractor CONTRACTOR: PLUMBERS ON CALL
',l' ARCHI'IECFS DECLARATION
1 understand my plans shall M used as public record
is isyV
y Licensed Professional
5OWNER-BUILDER DECLARATION
P 1 hereby affirm Nal 1 am exempt from Ne Contncmrs Liccnu Law for the
0 0 following mason.(section 703I.S.Business antl Profeasiom Code:Any city nr county
um which requires a permit m crewed,alter,improve,demolish,ar repair any structure
F z< prior o its issuance,also requires the applicant for such permit m file a signed migration
that he is licensed pursuantmthe previsionsOfthcCOnuatur'sLicense aw(Chapter 9 Sq. Ft, Floor Area Valuati$L8302
��a (commencing wi in SCe11On 7000)of Division 3 of the Business and Progressions Code)at s
3•- Nat he u exempt therefrom and the basis for de alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred delta.(SM. 35624022 00
❑I,as owner of the pmpcny,or my employees with wages as their sole compensation, +.. .9 A
will do the work,and theswctum is not intended Orafc.d fo..ma(Sce.7644,Buairexa
and Professions Code;The Contractors Liccnu Law it=not apply inan owner of d(Required!!lIInspections
property who Guilds or impmvea themon.and who does such work himselfor through his "1 10
/p
ownemploycer.proviii door sucbimprovemanum notintended OroRered formic,If, r(hcwcvar.the building or hopuravement is cold within one year ofeampletion,Ne owner, �/y�(•• ti V
builder will have clue,burdan of proving that he did not build of improve for purpose of �/sgpy).9y�[ `✓(gip / st�.
sale.). - �R' s9� / `r✓
❑1,es Owner of the progeny,am exclusively contracting with licensed contractors to
cone La the project(Sec.7614.Business and Py who Wilds
Coda)The Contractor's nd
ecru Lawdamnot
uch pr jean with
a cofpropcny.wbobuiidsorrant W me thereon.and
whenceLacontracts for such projects with a crnuacmr(s)Iiunzd pursuant to dhc Cantnnofs
Littna(ate.
❑ I am exempt under sec. ,B h P C far Nis season
Owner Data ,Vt�•"��'1'''��
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following do:Wmioru:
1 have and will maintain a Certificate ofennscm in self-insure for Worker's Compen-
1371W
on,as provided for by Section 37W of the labor Code,for Ne performers of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
of thc labor Code,for the performance of the work for which Its permit is issued.
Wogrkct nm enxation Insurance crie,end Policy nu nim,amrver: 1 Policy No.:A01.lZ65- fir
CERTIFICATE OF ExEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section recd not heeomplated if the permit is for me hundred dollars($10111
or legal
I eerdh that in Ne performance of the work for which this perm it is issued.1 shell not
employ any pecan in any manner W as to become subject o the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenificae of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J Z forthwith comply with such provision or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
P1 hereby elfrm that them is a construction lending agency for the performance of
IY
the work(ser which this permit is issued(Sec.3097,Civ.C.)
It7 Q Landers Name
0. Lender's Add.
a 2
U Q 1 cenify that I have read this application and sue that de above infmrratiun Is
ly f-' corn.1 agree to comply with all city and county ordinances and sue laws relating to
0Ubuilding commotion.and hereby authodm repmuntatives of this city to enter upon the
>"W above mentioned property for inspection purposes.
C. (We)agree to save,indemnify and keep harmless the City of Cuperono against
rrA liabilities,judgmens,cons and expcmes which may in my my same against said City
U in consequence of the granting of this permit. VV
^ APPLICANr UNDE TANDS AND WILL COMPLY WITH ALL NO -POINT Issued by: Dale
9
SOURCES LA NS/_J
Q Z Re-roofs
Sigm/icofe of Appicvcontmamr Dd1a Type of Roof
HAZARDOUS MATERIAfS DISCLOSURE
Will the applicant ser future building Occupant gore or handle no tnious material
az defined by the Cunino Mumci I Code.Chapter 9.11,and the Hcaldb and Safety
a1r,section zss3z(ape)7 /(u
71Y. All roofs shall be inspected prior to any roofing material being installed.
rNJu j
Will the applicant or 7LWIdingoccupant use equipment.1imvlcaa which If a roof is installed without first obtaining an inspection,I agree to remove
id becardme,air co ourinland by the Bay Arca Air Quality Management all new materials for inspection.
isuic"
0 Yes
1 have read the brallo rx materials¢quimmenu under Chep e,6.95 of the Califor-
hisHealth hSafetyCods,See'mu 155)5.35533 and 25534.1 undersusb Natirthe Wilding
docs not curemly have a n1,that it u my responsibility m nobly the emu sin of the
requirement,carr et vurinraneeeheertifineeraa Signature of Applicant Date
m —
Owner or authometl agent Dau 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:-Z 1 `d Z2 U n y L�- PERMIT #
S'ZJc� a2. S' Y
OWNER'S NAME: PHONE 6 5-/3
GENERAL CONTRACTOR: ,�— / FAX #
I am not using any subcontractors:
Signature Nate
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
CITY OF CUPERTINO
m,- REPIPE/SEWERS/MAIN SERVICE U S
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Bui din � Address:
1 2 Li
Owner's Na e: Phone
V)rj \� �L� U Pi L-I(- &C�)- V�)1
gntr r: � W r O License#/r:A
lu- vl C41
Con ct: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb EK
Job Descriptio
Okkv— JQ
Residential Commercial ❑
Cost of Project: 60O
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
47 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 I Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
3c �