03080161 CITY OF CUPEWFINO ' * '-1' p-- Ot
BUILDING DIVISION pI RMIT CONTRACTnR INFORMATION
BUILDING ADDRESS: PERMIT NO.03080161
7
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY 0. 04 NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�op LICENSED CONTRACTOR'S DECLARATION
I u 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
�Y with Section 7000)of Division 3 ofdw Business and Professions Cade.and my license is
; N LiceraeClumfull force deffect NAL.ED
z iicenmclass Lm.a REPIPE (COPPER) 1
x F-o Dow Contractor
ARCHITECT'S DECLARATION
f I understand my plana a hall he used as public records SEP 1 5 2003
S Licensed Professional
OWNER-BUILDER DECLARATION
2 I hereby afrim that 1 am exempt from Ne Contractors License Lew for the BUILDING C o following reason.(Section 703 1.5,Business and Profession Code:Any City or county ��
$9! which requires A permit to construct,else¢narrow,demolish,or.pair any Amcwm
-iy prion.its issuance,alsomquims sheapplicant forsuch permit to File a signedsumicns
ip
that he is licensed pursuant to she provision of the Contractor.Limnse Law(Chapter9 Sq.F[. Floor Area Valuat on
p5 t- (commencing with Section 7000)of Division 3 of she Business and Professions Cntic)or
`
that he Is eaempt Nerafmm and the India for Ne alleged cmmpothm.Any violation of
Section 7031.5 by any Applicants for a permit subjects Ne applicamrto a civil penalty of 00th Number _ _.. __Occupancy Type_. _
noimommhan five hundreddollan(5500). - "„' -'-'--- ---
❑I,ss owner of the property,or my employees with wagea u their sole compensation, ..pp ���p
will do the walk.and Ne structure:is not intended or offered for sale Business 301 - ROUGH Ire ySftus�I �eCt10nS
m
and Prefwion Code:The Conmetord Lienee 4w does not apply so an owner of
property who builds or improws shemoand who does such work himmlfor through his 502. — FINAL PL BING ENERGY
Own employees,provided that such improvements Art:not intended or Offered for Asia.If. 507 - FINAL PLUMBING '
however,the building or impwwment is veld within one yeti of complefion,the owner-
builder will have she burden of proving that he did not build or improv for purpose of
dale.). - -
I,As owner of the property,am exclusively contracting with licensed contractors to - - -
co Ban Ne project(Sec.Wad,Business and Professions Code:)The Conuacmr's Li. -
cense law does not apply to an owner or property who builds or improves Hereon,and _
who contracts for ouch projects with a contractor(s)licensed pursuant o Ne Contractor'.
Licenz Law. _
❑I am esu tpt oder Sce. ,B&PCfor Arco
Own y.
WORKER'SCOMPE ONDECLARATI N ”--
1 hereby affirm under penalty of perjury one of the follo ing tcclarnions: _.-
I haw and will maintain a Cenificam of Consent to mir-insure for Worte'sCompeo- _
&lion,m provided for by Section 37M of the Labor Code.for the performance of she _ -
work for which this permit is issued.
❑I ban and will maintain Worker's Compensation Insurance,as required by Section -
37W of the Labor Code,for Nc petformanee.I has work for which this pemtit is issued. '
My Worker's Cnmpenasion Insurance carrier and Policy number art: -
Cartier: Pol try No.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thissenion need not he complcted Rise rental,isfor one hundmd dolim(SIM)
ar In..)
1 cenify but in the performance of she work for which this permit is issued.I shall not
employ any person in any manner an As to become subject to she Worker''Compemnlon
Laws of CalifOrm Data
Applicant ,
NOTICE TO APPLICANT:If.after making this Cenifteam of Esempsion,you should
breome subject to she Worker:Compenmtian provisions of the labor code,you must
D O forthwith comply with such provisions or this permit&hall M deemed revoked.
CONSTRUCTION LENDING AGENCY
1 herehy affirm Na Nem is construction lending agenq far dm pcaurmmta or
x
for,work for which this permit is issued(Sec.3017,Civ.C.)
maA Lender',Name
3 z Lenders Address
;)O I certify that I ban mad Nis appticarion aM state Nu she above m onnuiun is -
.y F come,.I agree In comply with all city and county on inmen and some laws relating to
�U building convection,and hereby audsorine mprescnsaiins of this city to enter upon to
6wi ahovc )Are properly for Impaction purposes.
(We)
(Wc) gmeto cave,indemnifyand keep harreless Ci tyof ruCupcnst against
TA in COities,j fmC Of me granting
And g ex penes mit. may in Any way ettmc against said City
;J 7 A consequence UNDERSTANDS
of this permit
^r-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO Be REGU DNS.
2
Re-roofs
Signaure PEF..a✓Coalamm! Da
V HAZARDOUS MATERIALS DISCLOSURE Type of Roof
^ Will the Applicant orfor=building Occupant store or handle hammirds material
As defined by the Cupenum Municipal Code.Chapter 9.12,and the Health and Safety
c de,s eYes azss3z(a)+ All roofs shall be inspected prior to any roofing material being installed.
❑YpMu
Will the applicant or mture building occupant are equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.is hi ardour air conomimmus As de0ncd by the Bay Area Air Quality Management all new materials for inspection.
imel?
❑Yes VIS.
I haw mad es a
Ne lndous materiels requiremcau under Chepter6.95 orthe Califor-
aia Health&Safety Cale,Sections 25505,25533 end 25534.1 undermost Na:Fido building
dues
nos cu dy haw A tenant Nn is u my mmouniibiliry asnnOry do aosoust or be
5mgqui c whichmussWpdorwisumm Cemricamace Phoney. Signature of Applicant Date
owner or aamodaet agent All roof coverings to be Class"B"or better
CITY OF CUPERTINO c,W6 I
REPIPE/SEWERS/MAIN SERVICE
CUPEIkTINO PERMIT APPLICATION FORM
APN# D .
Z ' 7 �
Building Aqdress:4/262 K /
n 's Nam C
am7e1G ho e# � 7 7/�
o tr to Ph e: Li ense#:
C��SSo,tJ /�6 2S � -Z3 GS —
o t C P ne: Cupertino Business License#:
SSS
Bui ermit Info:
Bldg Elect ❑ lamb ❑
Job scriptio
Residential C6nimercial ❑
Cost of Pr
Qty- Llpc ��
•
A is bl Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pb] . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING