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ITY OF CUPERTINO
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BUILDING DIVISION PERMITCONTRACT,,nRINFORMAIIIQV:
r.:LDING
ADDRESS:
038 FR nR
A — ROOTER & DRAIN CO.
PERMIT ND.05080248
ER'S NAME:
PERMIT ISSUE DATETHOMAS
LOVE
P.O.BOX 24212
26 2005
NE:
JAICHITECT/ENGINEER:
SANITARY NO. CONTROL NO.
(408)266-7182
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o
LICENSED DECLARATION
Job Description
of CON
underCONTRACTOR'S
1 W rtby )firm that l am under provisions of Chapter 9
I am
port
Surge my iscndng
with Section ]011(p of Division }rf the BUJness and Profcssinns Cade, and my liccnu is
Bu
in full force and cffcm
REPAIR WATER LINE/SEWER LINE
License Class Lie. N
Dow Contractor
ARCHITECTS DECLARATION
I underitandmy plain shall W used as public recortls
Liccnud Professional
Pro
OWNER -BUILDER DECLARATION
I hereby Law for the
.(Rein that I am exempt from be Cssion,
LiAny
IIDL4 Business and Co c
following mason. Cade: Any city at county
mase
which requires Permit ere. demolish. nr repair any tatucwn
pesmio to
t alley. impmsu de
$ 5 2 0 Q
issuance. quires t e ermit t,
prior aridirecdprsuant be Uceuclaw(Chapin9
Wislicensed be thecant for such Permit to Law
Connector'sBusiness
Sq. FL Floor Area /0 anon
that to of the(Chapter
pursuant to
of Division professions Code) or
(commcncing with Section ]and Division 5 of the B
the cd creand
that he u exempt therttrom and the Esso for Any of
ctleged eumant
be
to
fon permit subjects be applicant a civil penalty of
Su don 7031.5 by airy it penalty
r
Oc cy Type
red doll
not mom th.n ave nanerea dread (gsoo).
❑ I.no mrofl piopeny,mmyemployseswithwagesu Neirulecompenution,
will do the work, and Iheatructum is not intended oruRered formic (Sec. 1011, Business
and Profusions Calc: The Contractor's License law does Out apply b an owner of
Required Inspections
property who builds or improves Chemo n. and who does such work hi muff or through his
own employees, pmvidcd Nal such improvements are notimended oroffeead for sale_ IC
however, the bmlding or impmvement is to within one year of completion. be owner.
builder will have the burden of proving but he did not Wild or improve for puryose of
sale.).
❑ 1. as owner of the property, am exclusively contracting with licensed comutors to
mnstrvet the project (See ]turd. Business and Professions Code:) The Conwcbrs U.
cense law does not apply to an owner or properly, who Wilds or imprmm themen, and.
who concocts for such projects with a contrutor(s) licensed pursuant to the Conmctoes
L'cence law.
I exemptu ee. .BkPC for this reason
Owner Date
WO KER' M ON DECLARATION
IW by allme under n y of perjury one of be following declarations:
Ihav<ane willm)nuin 'Ram of ConsemmCodcnsun fm
satirn, ss provitled far by tion 7]00 of the LaWr Code, for be pe)ormancc of Nc
performanceof be
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insunnce, u ¢,tired by Section
", of be labor Code, for tM performance of the work for which our permit is issued.
My Workers Compensation Matrnnce carrier and Policy number am:
Carier,Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This .6cm need nos W completed if the permit is fmonehundred dollars (SIM)
or less)
I certify thin in the performencc of the work for which Nis permit is issued, I shall not
shall
but in 0.
employ a in manners - ecmeub'ctt;Workerucd.I
dews sic
f C)ifo jk—
Applicem
NOTICE TO UCANT: If. t hating• u Ccrdficate of Ex Pace, you should
bttome aahjcct to the Worker pcuation previsions of IW Labor Code. you must
foMwith comply with such p cions or Nu permit shall he dccmed rtmked.
CONSTRUCTION LENDING AGENCY a
1 hemby alRrm chat then is. consuucunn boding agerey for the pedo.. of
the work for which this permit is issued (See 5097, Co. C.)
Under's Name
Lenders Address
I certify cut I have read this applicLlon and cute that the above Infotmadun is
correct 1 agrte to comply with JI city and county ordinances and state laws relating to
building construction. and hereby auburn representatives or but city to enter upon 0c
aWye-mentioned Property for iexpeNon purposes
(We) agree 1. save, indemnify and keep harmless be City of Cupertino against
estensesmitch may in any way urnteag)nitand City
intomquatdgmcndecrudand
inconsequence of be 8ranling of this permit.
NT U ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date '
SOURCE
_ �, 6--,o
u
Re -roofs _r.
goes Applicarn Date
H DOUSMATERIALSDISCLOSURE
Type of Roof
Will thcapplica�i r future Wilding oceuprnisiort or handle hoodoos maurial
u defined by the Cu ire Municipal Code, Chapter 9.12, and the Health and Safety
oda. Section Dy.2ssd2(a)] 8w-�
All roofs shall be inspected prior to any roofing material being installed.
Will Nc applicant or forum Wilding Occupant ore cyuipmcm or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
11 s air contaminants u d/efined by the Bay Area Air Quality Management
all new materials for inspection.
istrba]zmm
❑Yes mi
I have read be hvodous materials requirements undcrClupter 6.95 or be Critter-
hisHcalthd: Safety Code, Scctims 25505.25537 and 25534.1 understand that ifthe Wilding
does not inn ham ata Cha it or MY mapouihiliry m notify the Occupant of be
requtre bhm at or wormajoce of a Ocrok.u, or OcepIntocy. -
Signature of Applicant Date
All roof coverings to be Class "B" or better
2;g6'. d
.mQ
Community Development
10300 Torre Avenue
`' ' - %' Cupertino CA 95014
S
Telephone (408) 777-3228
CITY OF Fax (408) 777-3333
UPEkTINO
Building Department
JOB ADDRESS:
l t)39- N% i�pr- Die
PERMIT #
O 1- n ?0'2 n -c g'
OWNER'S NAME:
PHONE # 6 _Z
GENERAL CONTRACTOR: A- oor Co .
FAX #
I am not using any subcontractors: —s O�
Sign4 re
Please check applicable subcontractor and complex the following information:
60
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
er/Con for ignature
� 2
ate
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CITY OF
CUPEkTINO
CITY OF CUPERTINO��
REPIPE/SEWERS/MAIN SERVQCE
PERMIT APPLICATION FORM
APN # 36 2-
Date: Z 610-f
Building Address:
Dar
BPGAS
Owner's Name:
Phone #:
Or.n �o V
ti0 -
Contractor: Phone:
License 9:
- Rvotrr e h d I r- 2,G
'7 `a I .S .y
Contact: Phone:
Cupertino Business License #:
PLUMBING
BPWSVCS
Building Permit Info: F� n wtir ��ti 2l;^
lr rnQ
Bldg ❑ Elect ❑ Plumb Lr
Sewers
Job Description:
BPSEWAGE
e
PLUMBING
Residential Commercial ❑
Energy
Cost of Project:
� 5z�
BUSLIC
Business License
BUILDING
Qty. if
Annlicable Fee In
FPP rivenn ntinn
C.- !1.
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
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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