03030159 CITYOFCUPERTINO +4'��. AsBa: rr ` wrA
BUILDING DIVISION PERMIT GONTRAGTOR INFO MATION:
v BUIIDINGADDRESS: PERMITNO.
s OWNE PERMIT ISS
E. SANDARYN LNO.
ARCHDECT/ENGINEER: BUILDING PERMIT INFO
BIRO ELECT PLUMB MECH
0 0 0 0
300 LICENSED CONTRACTOR'S DECLARATION Job Description
ax 1 Mmby affirm thn 1 em IlaiuW under provisiou of Chep¢r 9(rnmmendng - p
< withSectim70lp)of Dlv4laa Sof the Business and!Profculmu Code,and my lice.It
r<,
in full Tarte and coat. .fFaRIALE®
dpi
License Class, LIc.N REPLACE SEWER PIPES'
Dam Contractor
IIE
ARCHC on DECLARATION
Iandmourdmypit.ahatl1emadupublic restit MAR 1 3 2003
s Licensed Professional
hg OWNER-BUILDERDECLARATION
2 f 1 hereby affirm that I am exempt from the Contrntm's License Law for the BUILDING
.
0 o following mason.(Section 70313,Business and Prefesslnu Code:My city or aunty
$ which requl..a permit to consumer.alter.Improve,demolish,nr repair any stratum
as^ pdorm its Issuance,also requires he applicant forsuch permit to rile a signed Statement ,
g@Kpx<
that Wis licensed pursuemmthe provisions nfthe Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
!do (commencing with Section 7")ofDivision 3ofthe BusineumlProfessCrum., SSO
II
that he is exempt them(=and the bub for the alleged exampdon.Any violation of pppp��.7j
Section 7031.5 by arty applicant for a mouluubjects the applicant to a civil penalty of 3-6zJ1'l � 0 0 Occupancy Type.
not more Nen Ove hundred dollen($500). ,
❑I,umvnmofthepmpeny,ormyemplo wlthwegesuthe4uke mpenntion,
will,Newark and the andctu ,is not lnmndroroReredfmule(Sa.70N,Buhmu eCt10I1S
and Professions Coda:The Contractors Lianm Law dna not apply to an owner of 106 - SEWER R&qW Actim;!p
Property who build..,bottom,tereon.mdwho doettah work himuaorderough his ,'ZO2 UNDERFLOOR PLUMBING
own employee..provided Net such Improvement,art not Intended oro@real foraale.IL
however.the building or Improvement is said within one year ofcrmpledon,the owner- 301 — ROUGH PLUMBING
Wilder will haw the Nolen ofprovkgshat Mdid amMid mbarrows for paryo.van .507 - FINAL PLUMBING
,1,as owner of the property,am exclusively contracting with licammd contractors to -
oamm Ne project(Sec.7014.Business and Professions Code:)The Comracmr's U-
ccae law door not apply m an owner of properly who builds or improve.Nemo..and,
who contract,for such project,with s comncm(s)licensed pursuant to the Commerce,
License Law.
❑\lame pt umimsec,�, B&Pciorthitmuon
Dw ed E�o .m
WORK ENSATIONDECLAR.tM
I hereby affon under penalty of perjury aro of l2fiell✓✓owing declarations•.
have and will retired.•CertificateofC.me.t m u)6kuref e Worker.Compere- -
ien,u provided for by Section 3700 of the labor Code,fNm the peronnance of dee
wart for which b permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,ss mqulned by Section -
3700of the labor Code,for the Mrformantt aides work rorwhich this preop is luded.
My Worker.Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thls.mdm need not be completed Ham armit is(mom hundreddollars(SIM)
I certify Net in the performu¢e of the work for which this pernb it Issued.I.hell not v
Lawaar .pa tug Iq�cab Ne Worken'Compcuation
mplay Cali rmutlz h
Appll L' _
NOTI��� PLIt.
AhBU"211,CeniOcnc of Exemption,you thoulJ
-
bpp��mme subject to the Worker's Compensation provisions of the laWr Code,you must
=z Yo7Nwl N comply with such provisions or this permit shall be domed revoked.
in CONSTRUCDON LENDING AGENCY
I hereby aRlim that Nem Is a convection lendingagency,for the ocrfurmaac of -
Oav> dee work fm which Nb permit Is issued($cc.3097•Civ.C.)
4 5 Lender's Namk �
D
Z I<nder's Add.
J 0 - 1 curtly that I have reed this application and sum that the be.InrmmNun 1,
y F comm.I agree to comply with all city and knurly ordinances and state laws relating to
`wV. building construction,and hereby authorize representatives of this city to enter upon the
aWve-mentioned property for Inspection pugtwes.
(We)agree m save,indemnify and kap harmless Ne City of Corcoran ageWt
r V) riabllitict,judgmengcosm and expenses which may in any way accrue againstsaid City
J 7 in conuqucnee of the granting of this Mouth. "A
F7 APP ANT UNDERST N ILL COMPLY WITH ALL NON-P Issued by: Date-
SO R R lJJ
Re-roofs ,
Slip6stlim of ApplianVC Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the ePoll=,or future Wilding occupant some or handle haurdous material
as dc0ncd by the ColonistMu clot)Code.Chapter 9.12,and tM Health and Safety
Codc,Section25532(s)? All roofs shall be inspected prior to any roofing material being installed.
❑Yet No
Will the applicantm utum building=open(use equlpmenl or devicdt which If a roof is installed without first obtaining an inspection,I agree to remove
It hwArdout air come inF-AeCtiAlS
defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Ya
Ihavemrthehasardmyulmmemorticr CTapmr 6.95 of the Califon
tie Health&Safcty Cade,Sections 25505,25533 and 25334.I edcrstand Natlfthe Wilding -
Jaor rtcntly hece a he Nn It I,my responsibility w notify the acupanl M Nc
mydlte w' res, iucancer..C.B. aP Signature of Applicant Date
. Omer nuthorirmd 08Qt - Dam - All roof coverings to be Class nBn Or better
r.
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM D 3 6
3 ° /s
APN# Date:
- 2 -
Building Address:
t`ln�ve v v�
Owner's Name: Phone#:
Contractor: Pho e: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ PlumbC .
Job Description: V�
Residential Commercial ❑.
Cost of Project:
Qty. if
A li le Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
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
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