05010012 CITY OF CUPERTIRAC
NO - -- _ '� r a4a'nt
BUILDING DIVISION PERMITCONTTQR,INFOTiMATION„ - "
BUILDING ADDRESS: ABLE SEPTIC PERMIT Nkb 5 O 10 O 12
10655 MADRID RD
OWNER'S NAME: PERMITISSUEDATE
ARNOLD NITE 520 REED ST.
ONE: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHTIECTENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
I� 0
LOo LICENSED CONTRACTOR'S DECLARATION
I hamby affirm that 1 an licensed ander provisions of chapter 9(commencing Job Description
with Section 7")of Division 3 of IN Bumina teM Professional Code.and my tic.is
>„ infull fo=and effect. NEW WATER SERVICE —
^�: License clasa Lk.taractor
lq- As mall be
in pI.s0.AT10N
a I wMcraund my glare shall be used es public Doccords
ECLARATION
�JY/
J�U /yam
3 c G Licensed Pndcssinn.l VV`
5 OWNER-BUILDER DE Ce ContrON
C I hcrchy,(firm that 11. exempt from the Cosions Co License Lew for the - -
p o following mina..(Saito Ro 1.5.Business and wn.derun Code:Any city or county
u$
which myaims a permit m rnnwstet,alter.impmw.aemmth,m repvr any urvewm - $500
prim m m x
in issuance,also mquirthe applicant forch Permit w Ole a signed sutement
��m< thin he is licensed pursuant m the prevision of the Common's Liccnx Law(Chapter 9 Sq.Ft. Floor Area Valuation
mFc (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
.- Net be in exempt therefrom and the btu for the alleged co mption.My violation of
Section 7031.5 by any applicant fm•permit subject the applicant to a civil penalty of
int more Man Ove hundred dollars($501y. -- -'— .. C - Occupancy Type - -
1,as..of the property,ar at employees with wegm ns Nei,sole compensation,
willdo Nework,andthemortumisnotinv dorofferrdfonale(Sec.]044,Business
and Pmfessio a Codc:The Contrames LiceLaes m an owner of
License Law donot apply -Required Inspections
property who builds a irepm mithemon,and whodoessuch work himse5fm Uvough his
own employees,provided thatsuch improvement art oat imtMW uronemd fmsale If, _
however.the building or improvement is sold within one year of completion,the owner- - - - -
builder will have Me burden of playing Nat he did not build or improw for purpose of
sal
tj I,as Owner of the property,M a chisively contracting with licensed contractors to
construct the project(See.7(44.Business and Professions Code:)The Cantamar's Li-
come Law docs not apply man owner of property who builds or improv thereon,antl ,
whoconmenfor such projects with a eonuaemr(s)licensed pursuant lathe Contractor's
License Law. k
❑Iem tic timers .B$PCfor this maven
O
dJ WORKER'S COMPENSATION DECLARATION
I hereby affirm under petalty of perjury one of ON following declarations:
(haw and will maintain a cenifintecar consent to self-imme for worker's compcn- . . _
sation,m provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 low and will maintain Wakces Compensation Insurance.as required by Section - _ -
3700afNelobar Code,for dm performance of the work for which Nis Permit is issued. ... __..
My Wallace.Compensation Inaunnce aria and Polity numhcr am:
Cartier. Policy Na: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not he completed if the Permit is Intone hundred dollars(SIM)
or lea)
1 certify that in the performance of the work for which this Permit t issued.I shall not
employ any person in any maoncrx as to become xbjcel m de workers'Compenaadon
Laws of California.Data - -- -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should -.- -
become subject m(be Worker's Compcmefion provisions of the later Code.you most
.JO forthwith comply with such provision O,this permitshill be deemed rewked.
Z ` CONSTRUCTION LENDING AGENCY
P:4 (hereby affirm that there is a construction lendingacne forth ^
agency Performance of V
G' the work for which this permit Is issued(Sec.3097,Civ,C.)
Ig1 0 Leader.Name
Z) LeMer's Addreaa
J Q I certify that 1 haw mad this application and sum that the about information is
t" comet.1 agree to comply with all city and county oNinances and sum laws relating to
0building construction,and hereby authorim mprnt
exatives of this city to enter upon the
Ushow-mentioned propertycosts
for ie penes which May
C (We)agree coove,indemnify and keep himuess the City of Cupertino against �r
N inconsegjudgmentegraoan ofthisxsmiichmeyinanywayeccrvcageinassaidCity \Jl
t.),Z m consequence of the granting of this permit.
^ APPLICANT UNDERSTAN S AN7WILL COMPLY WITH ALL NO -POINT Issued by: Date
SOURCE/ ULATIO S.
Re-roofs
So�Appla,mvLon azt r ' Date
✓� HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant score or handle hanndons material
as defined by the Cupertino Muni 'pal Cade.Chapter 9,13,and the Nostra and Safcry
tale.Scetie25633(,)?
Yees All roofs shall be inspected prior to any roofing material being installed.
❑
If a roof is installed without first obtaining inspection,I
Will the,pphe,nt or future building Occupant ax condiment Or devices which g an agree to remove P
:colt hamnio.air contmwnu a [mad by the Bay Ama Air Quality Management all new materials for inspection.
District? 'd1Y//
Dyes Nu
1 have mad the Wardens mammals requirement under Chapter 6.95 of the Califor-
nulkalth Safer,Code.Sxu.nM5.25533arv125534.1undasuMNatirN wiiding t
docs not any haw sten 4 Nu it y responsibility m notify the occupant of the
require oswhichm t eI 'or mtecofaCcniIt aIOccaP c Signature of Applicant Date
er rauthartcdage I Q,te All roof coverings to be Class "B"or better
r Community Development
10300 Torre Avenue
"✓ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
D
OWNER'S G/� ONE #
GENERAL:-CONTRACTOR: F #
I am not using any subcontractors:
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
v I- -Zoos'
er/C tro or Signature ate
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
35-6' O0p 0S^ 2— C�
Building Address:
�! /Dz o (/� VO4!
Owner' Name: Ph ne
Contractor: Phone: License#:
Contact: Uolr-� // T Phone: 76 Z9� Cupertino Business License#:
� h
Building Permit Info:
Bldg-- ❑– Elect ❑ ' Plumb ❑
Job Description:
Residential ❑ jj;T13
Cost of Project:
lica le Fee ID Fee Description FAPLUMBING
G
PPERMITFEE Plumbing Permit Issuance
i �' BPREPIPE Re i e of Fixtures 'BPERMFEE Bld . Permit FeesBPFIXTURE Pbl . Fixture i BPWSVCSMain Water ServiceBPSEWER Sewers
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
f