04020175 CITY OF CUPERTINO
BUILDING DIVISION PERMITxRA.OI'T
' OR �TO1tMA'C.If)N -'r;
BUILDING ADDRESS: PERMIT"0 4 0 2 017 5
OW NEWS NAME: PERMIT ISSUE DATE
NE: SANITARYNO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTOR'S DECLARATION O O O
Job Descri
I hereby affirm Nm 1 am licensed under provisions of Chapter 9(commencing w, w
a� with Soon..7DW)of Division 3of the Business arta Profession,Code,and my license is •�fi,VAir*LED
I.full fora and effect
Lima.Class ue.g GAS LINE FOR GAS STOVE
?�- Dam Contraamr MAR 1 8 2004
ARCHITECTS DECLARATION
I understand my plans shell W used as public records BUILDING
6
Licensed Pmfmsi...I
OWNER-BUILDER DECLARATION
iI I hereby affirm that I am exempt from We Contractors License Law for the
m O following mason.(Section 7031.5,Business and Professions Code:Any city Or county
$ which requires a Pewit to convect,alrcq improve,demolish.or repair any structure $i noo
Fzy prior m its issuance.also requires the applicant forsuch permit o Blc a signed statement
6 dtathCi611CCnsedpaRuanlleNepmV18i008nf1IMCnnVeCmftLlCcnsCldW(Chaptm9 Sq.Ft.Floor Area Valuation
(commencing with Section 7n W)of Division 3 of the Business and Professimu Code)or
.+
that W is exempt therefrom and We basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora pewit mbjeco the applicant to a civil penalty of 61�A14'I1103@6r0 0 O
not moa men five hundred delta.(0001. 3 GeD ParaC y 1'Pe
0 I,as owner of the property,or my employcea with wages u their sole compensation,
will d9 the work,and themmothe is not intended or offered fountain(Sec.7044,Business
and Predications Cade:The Cwtreemrs License taw does not apply to an owner of .Required Inspections
property who Wilds or i m proventhereon,end who does such work himself or through his
awn employees,provided unusual)improvemmta arc nmintended oroRered forasle.if,
however.We building or improvement is said within one year of complexes.the owner.
builder will have the bund,.of proving mat he did not build ar improve for purpose of
sal.j.
1.as owner of me progeny.am exclusively contracting with licensed contractors to
onswa me project(Sec.10C4.Beat..and Professions Code:)The Contnemrh Li.
camelaw dem t apply m an owner of property who Wilds or improves Merton,and,
who conhseta no
(or auch projects wide a cormactar(s)licensed pursuant m We Contractor's
License Law.
❑I am exempw der Sec. B&P C far this reason "
Owner D- 84
ORKER'SCC 4PENSAITON DECLARATION
I hereby under penalty of pejury one of lowing declarstiom:
illm -
Ihaveandwllm mre
CcrtiOof Consent to self-imarefmWOrker'tComper-
mile..as provided for by Section 37W of the labor Code,for We performance of We
wmk for which this pewit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of We labor Code,for We performance of the work for which this pewit is issued.
My Workers Compeustion boatmen carrier and Polity number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th6 secdon need not W complercd if the permit is foronehundrcddollars($100)
or less.)
1 comfy that in We perf came.of We work for which this permit is is..d,I shall not
employ any person in any mannerso as to become subject to We Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccntfrcate of Exemption,you should
become subject in We Worker's Compensation provisions of We lahm Code,you mut
.�Z, forthwith comply with such provisions or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Ihemby affirm that Were is a contraction lending agency for the performance of t
a the work for which this pewit u issued(Sec.3099,Civ,C.)
GQ finders Name
,=y LcnderB Address
U/Or 1 modify that I have read this application and stare that We stave infowNun is
IZ�F comets.I agree in comply with all city ad county ordinances and sate laws relating to
C)U building convection,and hereby anchorite representatives of this city to enter upon We
ren shove-me limed property for inspection purposes.
(We)agree to save,indemnify and keep harmless We City of Cupertino against
tai% liebilitien.judgmenta.caau and expenses which may to any wsymen.againatuid City
U7 inconseq accords, mingofthispermit.
r7 APPLIC NT UNDE TANDS AND WILL COMPLY WITH ALL NONPOINT Issued by:3Date
SOURCE EGO LA /
�112 u / Re-roofs
gnu no plumitCon ruder Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building ecupanumre orhanfic e.rdou material
as dented by the Cupe.im Municipal Code.Chapter 9.12.and the Health and Safety
ode,Section 25532(x)1
MAll roofs shall be inspected prior to any roofing material being installed.
Myna
�No
Will the applicant or future building occupant vu equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
It harmdous air commemaelt as lefned by We Bay Area Air Quality Management all new materials for inspection.
District? �/'
0Ycs WNo
I havemad theh=Mouussmamrlalsrequimmemsunder .Chapter&95ortW Califa>
nia Hcalth&S cry Cadc, 'ons 25505,25533and25534.Iundc.mndthazifWc Wilding
does not curm ly has,a I a t.that it is my responsibility m notify We occupant of the
requiremcros iehmust Prior to issuance OfaCcoifcamofOcc.p cy. Signature of Applicant Date
caner or igrboXkaunt Date, O ` All roof coverings to be Class"B"or better
1
CITY OF CUPERTINO od o/ 7sr
REPIPE/SEWERS/MAIN SERVICE
CUPEI �TINO PERMIT APPLICATION FORM
APN# /' .Z G C> o Date: a a � 00Ar
b a
Building Address: 0 6 9 W i-k y N A y
(upe ryNU CA q,501+
Owner's Name: A RuNA Go",474 N /sAmpATH Go MA7,gq Phone#: Ct og1 d55. M-0-6
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg Elect ❑ Plumb ❑
Job Description: CA-5 L,N 6 roe CAS Sra d 6
Residential tO Commercial ❑
Cost of Project: /coo
Qty�if�
A is b 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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