04090087 CITYOFCUPERTINO •'
BUILDING DIVISION PERMIT CON'TRA.GTUR�INP'CtRMATION"
a ILDINGADDRESS: GREAT AMERICAN PLUMBING CO P IT*Fo04090087
• OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY OLNO.
ARCHf1ECflENGINEER: r BUILDING PERMIT INFO
ELECT mums MECH
Bp LICENSED CONIRAC TOWS DECLARATION S Job D�ription
1 Wrathy affirm than 1 am IlCamed underpp rovii ons of Chapter 9(csmmeneing _ 1 ( , I
"pwith Scc'on70W)of Dlnsion3ofdo Susimm{ysaa��ttoofcanaoscode'so license is I \
a full ro d `� I
z unease Lk.. 01 D PROP. C/O &' HOUSE(:C/O,-(2-,WAY)
- Due i-f a=s4—CContractor ,e v
e ARCNRF.CI•S Da O! A6 1
y I understand my plana shall the land u puTiEeZ'i arch
3LL))
,-�
Licensed Pmfeasionel _-�-'
^
OWNER-BUILDER DECLARATION
iI botchy am.that 1 am axempt from the Conuectar's License Law for the
0 o following maven.(Section 703 1.5.Bananas and Professions Cada:My City Or county
$ which requires a pemit o convect,slier.Improve,demolish,or repair any structure
prim at its issuance.abu requires the applicant for such permit to Ela a signed statement
CzE< Nn he is licensed purwanito(Wprovisions oftheCarman'sumnse Law(Chapter 9 Sq. Ft. Floor Area Valuat on
CS (commencing with Suction 7000)of Division Sof the Business and Professions Case)or
3 Nat be is aumpt therefrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applium for a permit subjects the applicant to a civil penalty of 3-M41200hrO 0 Occupancy Type
not mom Nen five hundred dollar(5500).
0 I,as ownerof the property,ser my empoyces with wages as d¢ir sole mmpenudo t,
will Oft work.and the muc4urt Isnot intended m af4rtd for Wn(Sm.7044,Business Required Inspections
and Professions Code:The Comr gimes Lt.=Law doss not apply to an owner of e q p
Property who bWldsor Improve thereon,and who dolamh work romantic,Waugh his
own employees,provided that ouch impmvemenu ase nos Intended or offered for We.If,
however,the building or tmpmvcment is sold within am year of completion.the owner.
Wilder will have the burden of proving dot he did not Wild or improve for purpose of
ask.).
0 1.On owner of the property am esclunvely contracting with licensed comacmr to
contact the project(Sec.70".Business and Prowsatam Cade:)The Contractor's Lt.
Came Law dos not apply an an Owner of property,who bull"or improve thereon.and,
who contacts for such projects with a contractor(a)limned pursuant o we Contractors
License Lew.
0 I am exempt undo Sec. .B k P C for this maven
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby apron under penalty of perjury arc of the following declarations:
1 have and will maintain a CeNOCam of Cansenuoulf-insure fm Worker'aCompen-
uean,u provWed for by Section 37000f the labor Code.fund.performmm of rite
work for which Nis permit to issued.
❑1 basso and will maintain Wori els Compenamon Insurnce,u required by Section
3100 of we Laor Cada,for the ptsfo msuce of Ute work for which this pctmit is tuned.
My W rk�f�(a CoopeLasgpn InaunnCa certier and Policy nu W am:
n rNant.'�T'o )^('>�olicy No.: /��/00 1/���fe -�
CERTIFICATE OF EXEMPI]BKPRDII WOG' RKERS'
COMPENSATIOC;TNSUMNCE
(13b section and trot he completed if the permit is for ore Wndmd dallam(S 100)
or Ica.)
1 unify that in the perfnrmamm of the work Into which this permit is issmd.I shall not
employ any person In any monmrso as an becomesubject to the Worlum'Compemadan
Laws of California.Data
Applkam
NOTICE TO APPLICANT:IL after making this Cenificata of Emotions,you should
become subject an We Worker's Compensation provisions of do Labor Code,you muss
.,O forthwith comply with such provisions or fats Permit shall be deemed revoked.
z'y CONSTRUCTION LENDING AGENCY
[n I hereby aMm Nat then u a construction lending agency for the Performance of
CG Ito work for which this permit is issued(Sm.3097.Civ.C.)
Lender's Name -
0.. Z Lender'sAddnra
U Q 1 coolly that I have mad this application and seta that the move informatim is
F correct.1 agree o comply with all city and county ordinances and sum laws mating in
0Wilding construction,no hemby autharim mpresenmive of this city to enter upon the
r a Bove-mentioned property fm inspecdm purposes
(We)agree to says,indemnify and keep hamdess the City of Cupenim agWnst /x
4 Iimilidu,judgmenuns
,casts and expense,which may in my way serve gsaid d Cityin /
t.1 APPLICANTUNDERSTANDS
OD of thre of WILL COMPLY WI NON-POINT Issued by: Dat
SOURCEREGU qS
Re-roofs
Si o Applican Co eters Data
HAZARDOUS MATERT LS DISCLOSUR Type of Roof
WIII thO applimnt or fumm Wilding occupant sore or ltandk hauNous mamrial
as de0mn by the Cupertino Municipal Cade.Chapter 9,13.and the HoWth and Salary
'joLcmin,Seetian 25532(a)? All roofs shall be inspected prior to any roofing mate al being installed.
❑Yon m
Will the applicant a future Wilding occupant use equipment ars devtms which If a roof is installed without first obtaining an inspec ion,I agree to remove
mit haurdnm air contathinsna as defined by the Bay Area Air Quality Martagcment all new materials for inspection.
District?
0Yes �iu
I havemad thelurardma materiabreyviremenu under peer i93af the Glifar•
niaHwlth&Safety Cade,Senium 25705.31333 and 35334. rsmnd thetifthn Wilding
data not currently h a t.this it' my msponsi o 'fY tM acupant of Ute
myutmmc m m oiuvume cni0ca ofOccupenyy Signature of Applicant Date
mrmm Odin gent p,p 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
UPEI�TINO
Building Department
JOB ADDRESS: PERMIT # �
v-P, Ow`. / e o vl J l'
OWNER'S NAME: � PHONE #
GENERAL CONTRACTOR: -&z- ,-CA FAX # W� (l-(6
P &,� rn,
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
9—/T.,
r Contra or Signature Date
CITY OF CUPERTINO �7
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 -}591 (0
}C91O 03 Date:
Building Address: 6,L2 MJ Ie� Ave-.
Owner's Name:[ f l D Phone#: _
1 i�f'S�t S�O�`Ff,�✓��� h'QO• I y� ZS 3'��
Con -t6. � /P�ce: � `yam License�I
O
Contact J Phone* Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 0
Job De cri!ption: )
ks�o x Ae C( ati7� ✓� c Y� CJti ��S��q m-F
Residential ® Corrfmercial ❑
Cost of Project: y 2'I 00.00
1PP
if
1'cab a Fee ID Fee Description Fee Group
61 / 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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