05090019 , CITY OF CUPERTINO
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BUILDING DIVISION PERMIT iCONhTRACTO,R INFORMATION ,
OUI LDING ADDRESS: DRAIN DOCTOR PERMIT NOO 5090019
0114 MIRA VT.
OW NER'S NAME: PERMIT ISSUE DATE
ROBERT SUMMER 1775 WINCHESTER BLVD 09/06/2005
ONE: SANITARY NO, CONTROL NO.
(408) 370-3082
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
li00 LICENSED CONTRACTOR'S DECLARATION O O O
I Mreby afrion that 1 am licensed under provisions of Chapter 9 commencing Job Description
n.
with S.A..7").f Dirislo.3.f she Buri.and Bro(r��oQPAnn�li. :is
in m�force andertm.3b LV.Lf [qJ WATER SERVICE
j Licenm C Lk.N
Da¢ Convector.
EE ARCHITECTS DE LLACLARMeATIOmN o, 1t
-'self �D
?W U 1 undcrsunJ my plans shall W used u lll.��i.l
G G Licensed Professional
ni3 OWNER-BUILDER DECLARATION /,7_
<2 1 hereby offmn that I am.wmpT from IM Conuactoes License Law for The SEP /J 005
p0 following apn.(Sccdun 7031.5.Business and Professions Cale:Any city or county Cd�
xSr tai which rtyuires a permit to m
...4 slue,,impw,demolish,or repair any at
.M
y Z80 O
=2y prior to its issuance.also Rynires the appliQm for such permit to rile a signed stlNment
s< That he is licensed pursuant to TM previsions of the Contractor's License Law(Chapter 9 S Ft. Floor Area I` Valuation—
�eF$ (commencing with Seniors 7UW)of Division 3 M NC Business and Professions Cottle)of q �il 4 f1e \ .tt .�
_ That W u exempt therefrom and the basis for the alleged exemption.My violation of CCCIII lb tl VS "`z 7,
Section 7031.5 by any applicant for a permit subjects The applicant be a civil penalty of
not mom than fm hundred dollars($500), T Occupancy Type
1,ot owner of the proprsty,m my.,ima deed with wages as Nes sol.eompewness
will doIkworl,ns ande: he Contranots Liens Law do for Act apply
Business
and Professions Code:The Convectors License Law dors or apply tf an owner of Required Inspections
Ownpropertyem who builds or ire that
sudaemon,and who AM not
work of off mul Waugh his
ownemployees,providedthissuchimprovementsartnot ear of c m Melon.for salty If,
however.Nebuildingor impmvemennissold within one year of completion,the
builder will haw ,Ne WNcn of proving that W did tot build or impmw for purpose
om of of
sale.).
C]1,As Owner of the prop.ny,am exclusively contracting with licensed convenors to
consumer du project(Sec.70",Business and Professions Code:)The Contractors Li-
come law dors not apply To an Owner or property who Wilda or improves daemon,and
who contracts for such projects with acomrmtor(s)licensed pursuant o the Contractors
Late.law.
❑l am aempt under See. ,B&PC for this rtuon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRnm under penalty of perjury one of the following declarations:
I haw and will maintain a Ce,dfiam of Consent to self-imum for WmkersCMrpAm-
737W
an,u provided for by Section 3100 of the IaW,Code.fer tM performance of the
rk for which this permit Ts issued.
1 tout and will maintain Worker's Compensation Insurance u required by Section
of the Vbor Code.for the pcAomannee ofThe work for which this pumit u issued.
Workers COwtiO Imm�nce nrtia and Policy number artJprrie��'a,-Tan-IWO�l/�LL-s.n Policy No.:�S� - J ty
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is for one hundred dollars(I Iran
of Icse.)
I mni()v thm in the performance of the work for which this permit's issued,I she]not
employ any person in any mannerm as m become subject to the Workers Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate Of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
.J z foMwith comply with such pmvisious Or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
F IMmby M.Nat there is a construction lending agency for the rMfuremnee of
6i r Ne work fur which this p.nnir is issued(Sec.3097.Civ.C.)
[gl Q Undoes Name
lender's Address
�z
V 0 I certify Net 1 have read this application and state that the above information is
contact 1 agree Io comply with all city and county Ordinances and sate laws relating to
�(J building conumction.and hereby auNorire n:prescnuGws Of this city w enter upon NO
ction
ahowtms.judgedpmpca for i cape.PMPMwhich a
0. (We)agree m saw,indemnify and keep homeless Ne City or Cupertino against
to incenectimuceofth,costsAnd of thisu which may in anyway vert againnsaid City
C.3 z APPL CANTcUN UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER O
F_e, :)<— S
Si o/A IianVContrwtor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will TWaPrAicam or future building occupant uorc orhandlc hazardous manorial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
,AIIGodo,Section 25532tN)7
Pres P� All roofs shall be inspected prior to any roofing material being installed.
Will the&Mile (or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air con entinanv As defined by the Bay Arca Air Quality Management all new maters for inspection.
Diwict7
p Yes Nu
Ihaw reaJthe hvarvionsMmaterials 5,2553 irtments 5534.1 rdtisur6.95ofhe Caldmi;
nix Health&Safnyhaw a tendons anti my responsibility
mAmo rWe Occup Willing
does not cumen0y haw a unapt that it is my respomihility to nntily de acupmt of the �
rtyuiumcn uv W met prior m issuance of a Ccnlfeate of
a °iupuiy Signature of Applicant Date
Owns,a,aa(hormved Agent p,e All roof coverings to be Class "B"or better
z i Community Development
10300 Torre Avenue
Cupertino CA 95014
CITY� OF Telephone(408) 777-3228 UPE�ITINO Fax(408)777-3333
Buildin De artment
JOB ADDRESS: n,, PERMIT#
� r �' PERE
�o4ob�
OWNER'S NAME: PHONE #hod
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature D�—
Please check a licable subcontractors and corn Tete the followin 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 I
Owner/Contractor Signature
Date
aut
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
E
R,T
OF
SCUPINO PERMIT APPLICATION FORM
APN# 3�_z b Z 2� 1—� Da '_/_O
Building Add12� rq i„ _ v, b J
Owner's Nam l — ll _ \ Phone
Contracted���h _ / _ Phone: Licens
Contact Phone„/e CupertinBusiness License#:
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Building Permit Info:
Bldg ❑ Elect ❑ Plumb 2--�
Job Description: �4— v
�CQ
Residential Commercial ❑
Cost of Project-
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Dis osal PLUMBING
BUSLIC Business License BUILDING
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