04030026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CU1�1"TRACTOI2^"[�+1FURMA,TIN ,
BUILDING ADDRESS: CUPERTINO PLUMBING PER"""'04030026
L096 MILKY WY
OWNER'S NAME: PERMIT I%UE DATE
TAI-LING W
ONE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITECTIENGINEER
08 253-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
y O o LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal I am licensed under provision rf Chapter 9(commencing Job Description
with scctien]000)af Division Sof the Busines n .Prousighma Codo,and my license is
'A morn a errtqt. '— REPIPE
5'�i u.en c F — v see x
nilD m Convertor l �`
qq ARCHITECTS DEC O
a 1 unticraunJ my plena shell M tined as p orris AUG 15-2004
a.PG Licensed Professional
OWNER-BUILDER DECLARATION heroidling
BUILDING
/�
<� 1 hy m NI am exempt from the Comacmra License Lew for the
E n oo following reason.(Section 703 1.5,Business and Prefeuiom Code:Any city an county
which requires a Permit to construct,alma improve,demolish,or mpoir any swemm
t- �^ prior in its issuance.also requires the applicant rorsuch Permit to file a signed statement
�< thalheislkcnscd punuantmlhepmvislarmnfthe CenIMWnSUURWlaw(Chapmr9 Sq.Ft. Floor Area Valuation
c�to (commencing with Section 7000)of Division Sof the Busineasand Profession$Code)or
'list he u exempt therefrom and the basis for the alleged eamptiad.Any violated of
Section 7031.5 by arty applicant for a permit subjects the applicants a civil penalty of 3�N0Qfii'Ber Occupancy 0 0 OccU e
not moa than fiw hundmd dollars($500), P y Typ
❑1,as owner of the property,or my employees with wages m their sale compensation,
will do the work and theswmure is not intended or offered for side(So..7044,Business
and Professions Code:The Condemner License Law docs not apply in an owner of Required Inspections
property he bui Ids m i m proves thereon.and who does such work himself m through his
own employees,provided thetsuch improwmentsaa not intended unaltered forsale.IL
however,the building or improvement iaaold within one you oreompletion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1.as owner of the property,em exclusively comnaming with licensed convectors to
construct the project(Sec.7006,Business and Prof eadona Code:)The Contractors I.I.
cense Law does not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projecis with a conmcmr(s)licensed pursuant le the Containers
License Law.
❑1 am exempt under Sec. .B @ P C for this amen "
Owner Data
WORKER'S COMPENSATION DECLARATION
INI hereby alarm order penalty of perjury..of me following de.le aliens:
1 have and will maintain a Certificate of Consent lowif-imuro fer Worlog's Compcm
talion,as provided for by Setting 3700 of the labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imuo nce,as required by Section
3700 of the labor Code,for the pmr.mar dm of the work for which this permit is Issued.
MyWorker��' Cyym�p auanffl--n—ssuranc��e carrier and Policy number am:
mer. T�T� Rly s Pongy.po.:'j�Cycf-'--
CERDFICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('nils section need Wt be completed if the Permit la formic hundred dollars($I M)
or less.)
I cagily that In the pufterrance of the work for which this Permit is Wood,I shall not
employ any person in any manner an m to become subject to the Werecri Compensation .
Laws of Califomie.Data
Applicata
NOTICE TO APPLICANT:IL sMr making This Comficsm of Exemption.you should
become subject to the Workers Compensation provisions of the Letter Code.you must
.J Z forthwith comply with such provisions or Nis Permit shall W do mil revoked.
zO CONSTRUCTION LENDING AGENCY
tti (hereby affirm that there is a construction lending agency for the Performance of
Ni > the.,it for which this Permit is issued(Sec.3097.Civ.C.)
WMA lendcn's Nam.
z Lender's Addams
V Q I certify that I have mad this application and tuts that the above orientation is
ITn E Correct.]agree to comply with all city and county eminences and sum laws misting In
C) building construction.and hereby authorise mpreumadves or this city m enter upon the
(17
move-mentioned property for inspection purposes.
0.
(We)agmen to save,indemnify add kith may
in m the City or Cupertino s against
p)
liabilities,judgments,costs
nortio expense,which may In any way eceroe against said City
fJ7 in consequence of the granting of to Troll.
APPLICANT UNDERSTAN - D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEE �_
Re-roofs
S' sea o r Comm r Out
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
will'lncapplicanlor fumy build cupanumrc or haMlc havardous memriai
as defined by the Cupenine Mumc ode,Chapter 9.12.and the Health and Safety
oda, ezs25532607EYes ❑Nu
All roofs shall be inspected prior to any roofing material being installed.
❑
will the aP,Iicant or m a-banmi opens use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit lineaments air comaminanu u cd by the Bay Ama Air Quality Management all new materials for inspection.
District,
0 W Nu
Ihavc mol the hvamnusmmcrialsaquircrnenv under Chapterh.95 of the Caliror-
nuHcalth&Safely Codo Sccuona 75505 end 25534.I understand that if thc Wilding
Jou not currently have a tenant Y to rectify the aeupart of the
uwhi ac.nin.amerOccupm..� Signature of Applicant Date
owner en ri.ed cot Due All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDREW,
PERMIT #
OWNER'S N �t �n a PHONE 9? — / /
GENERAL CONTRACTOR:
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 ��no Pww�l
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/ on 'actor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE 0
CUPERTINO PERMIT APPLICATION FORM
APN # I
Date: .
Building Address:
Owner's Name: / 4-g,
� hone #.
Tyr brM y� 973 - I 1
Co,�tractor: Iho : icense #:3'6U C�z�goCo ct Cupertino Business License #:
Building Permit Info: i
Bldg ❑ Elect ❑ Plumb
,90
Job Description: n
C
Residential Corhmeecial ❑
Cost of Project:
L�
Q . if
/4pll,cuble Fee ID Fee Description Fee Gro
up
PPERMITFEE Plumbing PerMeM
ING
BPREPIPE Re i e of FixtING
BPER�IFEE Bldg. Permit FG
BPFIXTURE Pb1g. FixtureING
BPWSVCS Main Water SeING
BPSEWER SewersING
BPSEWAGE Sewa e Dis osPLUMBING
BUSLIC Business License BUILDING
a � 7