05070052 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONCRA.C4TQ,RiINF0RM'ATION
ism LDING ADDRESS: WATER QUALITY PLUMBING PERMIT'cb5070052
OWNER'S NAME: PERMIT ISSUE DATE
MARGARET S ADBURV 1890 ALM nFN RT)
INC: SANITARY NO. CONTROL NO.
(408) 267-9330
I
CHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONlob Descr-I bertby affirm Nat 1 am licensed under provisions of Chapter 9(commencingh Section]Wl)of Division Sof NC Business and Profcssium Cada.and my limits,isu.mmmaeR a g REPIPE (BACK UNIT ONLY)
��� Lkcnx Cl LIc.A
n—p Dolc�Contractar
ARCHoEgrSDECLARATION 2005
C9!6 Imdcrm yjlns shall du,ohlic records - BB /
CyU LLA n B�I��'
+o is Lteeme Pmf (� p
g 3 OWNER-BUILDER DECLARATION \Y.
E M 0 I Wrehy.mere on I em exempt from Ne Conmcmes Liccnu Law for tW
E
p o following rtuon.(Section](131.5,Boniness and Pmfessiom Cade:My City or county
e m which requires a permir us construct,alter,improve,demolish,or repair any structure
prior m its issuance.also heriins the applicensforstad permit to file a signed statement
i e
hast Ise is liecrecil purnmant to tho provisions of the Conmaxim's License Law(Chapter 9 Sq.FL Floor Area Valuation
xF$ (commencing wit Section 7000)of Division 3 of Me B usinex and Professions Code)or
that M H exempt therefrom and the basis for the alleged c mnpuon My violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of 3 6' I iBetO 0 Occupancy
not more than five hundred dollars($500). Pane Y Type
❑I,mo =oftitepmpmy,mmyemplo wMN ra asthebmlecomperuauon.
will do the work,and the absolute is not intended oroRered formic(Sec.7044,Business
Add Proessimix Code:The Continences License Law dors ret apply in an cams of Required Inspections
propeny who Wildsorimproses thereon,and whodoessuch work himxlfor through his
own employers,provided that such improvements arc not intended araReted formle.IL
howewp the building or improvement is sold within one Year of completion,the owner.
wilder will Law on burden of proving than W did art Wild or improve for purpose of
mak,.).
❑1.u Owner of tie property,am exclusively convicting with Iiremed commons in
constmct the project(sec.7044,Business and Professions Code:)The Conwcmr's Li.
come Law diem not apply An an owner of property who Wilds Of improves thereon,and '
who cro m ix for such projeens with aernmcmrp)licensed pursuant in the Conuutoem
License law.
I am exempt under Sec. ,B&PC for ilia reason
Owner Dam
WORKERS COMPENSATION DECLARATION
I hemby,Kinn under penalty of perjury one of the following declarations:
1 have
and will meinuin eCertifiamof Camera w self-imurt fm Warkeh Compen-
anon,as provided for by Section 3700 of the labor Cod,for the performance of Ne
work for which this permit is lamed.
❑1 have and will maintain Worker's Compensation Insurance,ss re,,uirtd by Section
3700 of the labor Code,for de performance of the work fm which to permit is issued.
MY
ciWo: CampensauonIn�Rsu - certiuAnd Policy 0A •3
Carrier: L11 1\ Poliq Na:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
or kms)(Ib6 section need not W completed if tin: .it is for one hundred dollars(510B)
I unify,Non in she performarcc of the work for which this permit is issued,l shall am
employ any prison in any manner an az e become subject o the Worken'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this CcniOcam of Exemption,you should
become subject in the Workeri Compensation provisions of thc Labor Code,you must
.J z forthwith comply with such provisions or this Permit shall W defined oc okc&
z O CONSTRUCTION LENDING AGENCY
'r+ Ihereby affirm than tort is a construction lending agency for the Performance of
a the work for which this permit Is issued(Sec.3097,Civ.C.)
W A Lender's Name '
z LonderYAdd.
V Q 1 certify that I have read this application and state that the above information u
D. H correct-1 epee m comply with HI city and county ordimnm and abs laws missing in
O[, Wilding cenatuction,and hereby autharia¢pciamnatives of this city to enter upon the
CL awve-menuunedpropcllyst for dcaricuoa purrowhich MAY
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
E+fA
in
consequence
onets.grand And eapeausmit. mryin anyway acetum against said City
U z in eonxquesme of the granting Of this Permit
^ APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL NON-POINT Issued by: Date
SCEIREGULATION ^/1 14
Sigraurt Dl tcadu anmcmr ( V ' Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant atone or hardlc haraNaus material
As deft ed by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Adifindit.Secuon 355320)?
❑Yes tip All roofs shall be inspected prior to any roofing material being installed.
Will the applicant arffuture building occupant tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haudnus air conbmimnts as ticfincd by the Bay Ara Air Quality Marugemcm all new materials for inspection.
suict? /
❑Yon �❑N.
I have mal the hannious materials mquiromenu under Chapter 6.95 of he Califor
ria HUM&Safdy Co@,Sm4ons]5505.25533 and 25534.I undcrmad this ifdc Wilding
dw not currently have a tenant tis it u my rommom 'ity in notify the occupant of the
require L, hichmustWmetp'or ...of. nificalcor0ccu m. Signature of Applicant
Date
Owner m autoriud ascot Date All roof coverings to be Class 'B"or better
CITY OF CUPERTINO vs
REPIPE/SEWERS/MAIN SERVICE
' OF
CUPERTINO PERMIT APPLICATION FORM
APN 3(0R i 90(4 Dater ^�
Building ddress:
Owner's Name: Phone#:
Contractor: II Phone: Licen�.e,#:
j t
Contact: Phone: Cupertino Business License#:
\t-
Building Permt Info:
Bldg ❑ Elect ❑ Plumb
—
Job Description• S
cP
Residential Commercial ❑
Cost of Project: \
Qty. if
A licable 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
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal— PLUMBING
BUSLIC Business License BUILDING
3 A 2AIJ
: �� 37