04020083 ' CITYOFCUPERTINO g'� '�,tt� ....
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BUILDING DIVISION PERMIT CONTRACTQA IN'FO't2MATI`UN ,
'UILDING ADDRESS: ACE PLUMBING PERMIT N0.04020083
119-71 MlRil. ITTST-A AV
OWNER'S NAME: FERMITISSUEDATE
NE:
SANITARY OL NO.
10;
HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0 0 0
:OLICENSED CONTRACTOR'S DECLARATION JobDescri tion
ut Wreby afOrm the,l em liocnsed under provisions of Chapter 9(commcoe mg p
a - flhe Bu sine PmfcsxiunsCade, m;Ii i_❑<� ll fo cttect.�qzLcenoc LM.♦ ll--R-,,EPIPE SEWER LINE FROM C/O
"j" Dam AR ITELTS OEC Tl t If""\ �� �
1 undenend my plans shall W usedCo. blic records
3 Liremmd Pmfm&iamal FEB 1 q 2004
OWNER-BUILDER DECLARATION
S I hereby affirm that 1 am exempt from the Comractar's License Law for the
O O following moron.(Section 7031.5,Business and Professions Code:Any city or county ��'�®'
$�u which requires a permit m consumer,atmr,improve,demolish,or repair any structure
Fly roarer its ismance.atso requires,W applicant frrsuch pennitio Eleaaigned datomuem _
Nat he is licensed pursuant the pm ..
visionsof Ne Command',Lt .law(Cheptcr9 Sq.Ft.Floor Area Valuate n
(commencing with Section 700M of Division Sof the Businessand Pmfcaaiom Code)ar
y $ that he is exempt tMmfrom and the basis for the alleged exemption.Any violation of
Second 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3g1'�j7T ege�erp0 Occupancy Type
no,mod,Nan five hundred drlhn($500). -
(]I,as owner of the property,Or my employees with wages u their sole compensation.
will do the work and the saacture is not intended or offered for sale(See.7044,Business
and Pnefesslons Coda:The ConeractoYs License Law does not apply b an owner of Required Inspections
Property who bui Ids cr improves thereon,and who does such work himself or,hrough his
ownemployccs,provided thaLLuch improvementsed,natimmndedoroRemd formic.If, ,
however,Ne building or improvement is sold within one year of completion.Ne cower,
builder will have the burden of proving Na,he did not Wild or improve for purpose of
sale.),
❑I.as Owner of the property,am exclusively connecting with licensed contractors in
construct the project(Sec.7044.Business and Professions Cade:)The Contractor's LI-
came law docs not apply an an owner of property who Wilda or improves Nemon,and
who contracts for such projects with a convector(&)licensed pursuant to Ne Convacmr's
License Law.
❑I an exempt under Sec ,B&P C for this msson
1107M
wner Data -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury arc of to following declarations:
I have and will maintain a Ceruftca n of Consent self-insum for WarkerS Compen.
iro,Oce provided far by Stttian 3700 of the labor Code.fat the peRarmence of the
rk for which Nia permit is issued.
I have and will maintain Workers Compensation Insurance,as mquid,d by Section
of Ne tabor Code,far Ne performance of ma work fm which this Permit is issued.
y Worker's Co peer Ion Ins Ijance cam r and Policy num r am:,�',�,�,��Polk 692
CERTIFICA OF EX PrKWTROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed If the permit is(mode hundreddaliens(Sloe)
or Ica&.)
I ccnify Nat in the performance of me work for which this Permit is issued,I shall not
employ any reform in any manner so as to become subject to the Workers Campenss ion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making his Ccnificate of Exemption,you should
become subject to Ne Worker's Compensation provisions of the tabor Code,you must
.J O forthwith comply with such provisions Or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[-ice 1 Whebyaffrm Na,there is a conduction lending agency jar the scaurmence of
C(.> dm work for which this permit is issued(Sec.3097,Civ.C.)
A Lender's Name
z tender's Address
V I codify that 1 have read this application and some Nat the above information is
(y correct I agree to comply with all city and county ominances and scale laws misting in
O V building construction,and hereby namories, of this City to Order upon the
r� above-mentioned property for Inspection purposes.
(We)agree b save,indemnify and keep harmless the City of Cupertino against
rto imbillun,judgmenu.costs no expenses which may in anyway seem agalnatseid City
U 7 in consequcnee of Ne granting of this permit
'7 APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S U CE GULATf0
� Re-roofs
App'am/Conuanor ate
HAZARDOUS MATERIALS DISCL E Type of Roof
l dm applicant or future building occupantsmrc or andlc ha'rardous memritl
tW Cupertino Municiral Codc,Chapter 9.12,end Ne Hcelth and Safety
es zss3z(anyNAll roofs shall be inspected prior to any roofing material being installed.
tics NuA(by
If a roof is installed without first obtaining an inspection,I agree to remove
l the applicant or future buildin6 ottupam use cyuirment rr devices whichous air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection.
es t�(u
1 have mad the ha serous materials requirements under Chapter 6.95 of the Califor.
ria Health&Sa2tyCode,Sections 2550,25533 and 25534.1 undersWid that if in.Wilding
dam no currently haw a mnam,that i,is my responsibility m notify the occupant of dc
rcyui ants which most be met poor an Issuance of a Cenl em of Occupancy. Signature of Applicant Date
tuner ar a rmed agent , All roof coverings to be Class "B"or better
CITY OF CUPERTINO
40 REPIPE/SEWERS/MAIN SERVICE T
CUPERTINO PERMIT APPLICATION FORM
APN# 33-1
- DZO 3,�— Date:2//
`/Z)
Building Address:
t02 a, -b
Owner's Name: Ba Phone#:
B ; 1 s o -,k3vP
Contractor: Phone: License#:
Contact: Vi Phone: Cupertino Business License#:
Ta e�K
Building Permit Info:
Bldg ❑ Elect ❑ Plumb L10
Job Description:
o r er -m a,l 646,eAv ef t e
Residential ® Commercial ❑
Cost of Project: _
•
Qty .
A c ble 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