06020130 7
CITY OF CUPERTINO 7711771771. �' 'P"` 4NUA ed
BUILDING DIVISION PERMITCONTRAC' OR`INk`URMA'CION ':!T
."I w i. a 3'%•"5pY H10-�-.3+ s 'd,ay .
BUILDINO ADDRESS: rI'I(' PERMrT NO.060 2 0 13 0
21851 LOMITA AVE
W NER'S NAME: PERMITISSUE DATE
GARY LEE 520 REED ST. 02/22/2006
ONE: SANITARY NO. CONTROL N0.
(408) 377-9990
ARCHI]ECffENGINEER: BUILDING PERMIT INFO
ELECT PLUMB MECH
/ � 0
30p LICENSED C06fnRdunderSDECLARATION
onsofCap JobDeSCrI ti
tz 1 hereby 0)of Wil 1 am licensed under nal Pro es of Chapter 9(commencing p
< . ullfnonndMofDiHaion]ofJhcBusiness uMPmfcWumCode,antlmylicenxis SEWER & WATER SERVICE
n � in fullforaand elle Z 91407
3�? DatewClass _ — Contractor MAR 2U06
ARCHffECI'S DECLARATION
y 1 undersand my pl....bell W used as public=a,& {pgy 6nt�y
be Licensed Professional �U��6 tr �
OWNER-BUILDER DECLARATION RL",
iA S 1 homey affirm that I am uempl from the Conuacter's License Law for the
C O o following amour.(Section 703 1.5,Bananas and Pmfemiuro Code:Any city or county 6 O O O
$ which requires a permit to cnntrocr.suer,improve,demolish,or repair any muctum
_ZS9 prior to its issuance.aim require the applicant far such permit to file a signed summem'
<
that he is thermal rotational o Me provisions of Me Conusmr's Umose,Law(chapter 9 Sq. Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Bu.ines and Norwalom Cents)or
that W is exempt Motorman and the basis rte me alleged exemption.Any violadon of
Section 7031.5 by aro'applicant for a permit subjects the applicant to a civil penalty of r Occupancy Type .
not mom Nan five hundred dollars(MN
❑I,u owner of the property,or my employ=with wages as their min compensation,
will do the wok and the.W=are is not intended oralRsed fo Ws(Sec.7044,Bushiness
and Professions Codc:The Contractor's License Law d=not apply a an owner of Required Inspections
propeny who builds or improves rhercon,and who does men wok himself or though his
awn employes,provided that such impmwmenu an,not intended oaRered for We.If.
however.the building or improvement is sold within one year of completion.the onamr.
Wilder will haw Ne burden of proving that he did nm build or improve far purpose of
ale.).
❑I.as owner of the property,.m exclusively contracting with licensed contractors in
comtmct the project(Sec.7011,Bmtnea and Professions Cade:)The Com.emfs U.
come law d=not apply to an owner of property who Wilds or improves Merton,and
who contracts for such projects with a conrranorts)Hemmed pursuant to de Cantr.noes
License law,
❑lameaemptundo Sea ,Bk PCfothisnWon
137'W
ast Date
WORKERS COMPENSATION DECLARATION
1 Wreby affirm under penalty of perjury ane of the following declarations:
I have end will maintain.CeniOnteaf Consent m telf-lmem far Wotrh Campen-
ion,ss provided for by Session 3700 of tad labor Cade,for tie iscolo mmen of Ute
rk for which this permit is issued.
1 haw and will maintain Workers Compensation Inmnnce,as required by Section
ofrhe labor Code.for site performance of the wok forwhich this permit is issued.
Workces Compensation Inoance cumarend Policy numbs am:rder: Policy Na.: ` :
CE FI ATE OF EMFTION FROM WORKERS
COMPENSATION INSURANCE
(ITB sealenneed nor W completed Ifore Penal,is fmone handed dollars f ildr)
or less.)
1 really Nat M the performantt of the work for which this perch is Wood,l shall not
employ any person in any manner an as in hemea,subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Workels Compensation previsions or the LAWr Code you mus
.,O forthwith comply with such pmvimons o Nis permit shall W domed revoked.
,z.t " CONSTRUCTION LENDING AGENCY
F I for w .Yore the them m a construction(Sm. 0 rending agency for the performance of
tZ the work for which 440 permit is issued(Sec.3097,Cih,C.)
WM Q Lender'.Name -
0 z Iander's Address
V Q 1 certify that I haw mad this application and sate that the aWve information is
u(~ MMCL 1 agree to comply with all city and county ordinusd and man laws relating to
0 t.7 building construction,and hereby.uthoriw representatives of this city r0 carry upon the
f17 above.mentioned pa0peny fo lmpecdon patpoxs,
(We)agree to an,indemnify and loop harmless the City of Cupertino again,
vis tzo Iiabllides,judgmcars,cmu and expenses which may in any wry aana against sod City
C)"" in APPLICANT UNDEof the RSTANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
7G�P C4 L, 2-22-OI Re-roofs
Signmue of ApplicenuCon for - Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant mom"handle hamaduus material
u defined by Ue Cupertino Municipal Code.Chapter 9.12,and tie Health and Safety
0 et 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
If a roof is installed without first obtaining an inspection,I
Will the applicant or(uwre Wilding aceupam use equipment o dcvi=which g agree to remove p
It havardaus air conmrtinanm as dcOncd by the Bay Area Air Quality Management all new materials for inspection.
Disvin]
❑yes ON.
I haw read the heonadous materials rcquie roma under Chapter 6.950(the Califor.
nia Hal"Safety Cock,Seedan 25505,25533 and 25531.1 ucutsn
add than ifnco Wilding
d=act currently haw a mnanl tau it is my responsibility to entry the oaupant of the
requirements which mus be met prior to issuanm of a CeNOam of Occupancy. Signature Of Applicant Date
SnsQ_ Cfjz 2-ZZ-0 6 All roof coverings to be Class"B" or better
Owner at authortred agent Dam
Community Development
10300 Torrc Avenue
it So
Cupertino CA 95014 1,
Telephone(408)777-3228
CITY OF Fax(408)777-3333
#UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
Z less ( D kA 17 R A VT oho zo d
OWNER'S NAME: PHONE # plt 9990
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: Sc)S. GC J Z_ 2 "2 7" o6
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
r_x CITY OF CUPERTINO
C REPIPE/SEWERS/MAIN SERVICE
CUPEk�jIN10 PERMIT APPLICATION FORM
APN# ?-,7 `/ o C Date:2 - 22- OC
b
Building Address:
219,51
0 v -
Owner's Name:C
Phone#:
Contractor: Phone: License#:
PRISU U q
Contact: Phone: Cupertino Business License#:
g 3 0 2 114 0
Building P rmit Info: flew 5e\..3 e,r Ctr\ d Uja t Se; U RC2 i��✓ G� �^ ocR—
Bldg ® Elect ❑ Plumb ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING