03020062 CITY Or CUPEWrINO �ahlor
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO.
ABLE SEPTIC
A APPLICATI
520 REED ST.
PHO
(408) 377-9990 SANITARY I NO2. CONTROLNO.
ARCHITEC NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'+x+00 LICENSED CONTRACTOR'S DECLARATION
0¢ .I bercarn
hy rm that I am uanaed under previsions or Chapter q(commencing Job Description
n<R with Section Wari of Division 3 of Ne Business and ProfessionsCde.and my license is
,
in full fo c end tett.
SNa Lianroc` s�"r'—��2 ue,gJU� 77%75 SEWER PROPERTY LINE CLEANOUT
Date Contractor INAl.EIn
Y ARCHITECTSD uhlicranOrd
Y undcomnd my plans shell he use
3 Licensed professional OWNER-BUILDER DECLARATION FEB 1.'9 2003 -
_O
+�<I 1 hereby affirm that I am exempt from We ConuaOnr's License Law for the
00 following ateuo.(Secdun 7031.5,Business and Pmfessiom Gide:Any city or county
$ which requires a permit u)coarct.alar,improve,demolish,or repair any structure
FZ + prior to is issuance,also requires lWippllcam forsuch permilau file __ BU11
£�o that he is related pursuant to Ne pmvisiom of the Contractors License Law(Chapter 9 Sq.F[.Floor Area l� tion
e( $ (commencing with Section 7080)or Division 3 of the Business and Pmlessiona Code)or
— Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of -
Section 7031.5 by any applicant fors permit subjects Ne applicant to a civil penalty of
not mom man Tim hundred dollars($500). 32VY L,�7,187 rO0 Occupancy Type
❑1,as owner of the property,or my employees with wages u their$Die compensation,
will do me work,and the stmchee is not intended or offered for sale(See7W.Business 202 — UNDERF1dqQadELWffiiWG
and Professions Code:The Communities Liartse Law does not apply in an owner of
progeny who bundsor improve thereon,and who doessuch work himselfor through his ',301 — ROUGH PLUMBING
own employees,provided that such improvements arc not intended or offered for sale.If,
however.me building or Improvement is sold within one year of completion,me owner- 502 — FINAL PLUMBING ENERGY
bonder will haw the burden of moving mat he did not Build or Improve for purpose of 5 0 7 — FINAL PLUMBING
sec n.).
❑1,as owner of the property,am exclusively contracting with licensed co.omms to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
moue law does not apply to an owner of property who Wilds or improws bemon.anti
who comment for such pmjeeu will a contortions)liamed pursuant to the Contractor's
License Law.
❑1 and exempt under Sec. ,B&P C for this intend
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following Welarations:
I haw and will maintain a Certificate ocImscm to self-insua for Workeh Compere
Mian,as provided for by Section 3700 of We Labor Code,far the pedomarom of be
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of me Labor can,for da performance of the work for which this permit Is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Gani7cr:�5'I'atTl �.a�n d Polity ND,: 6157-0
CERTIFICATE OF EXEMPnONFRG KERS'
COMPENSATION INSUR E
(Thu seat.need not heeomplead if the permit is fora..hundred dollars($N))
or less.)
I certify mat in the performance of the work for which this permit is issued,1 shall nut
employ any person In any manner w a in become subject o the Workeri Comperoatlon
Laws of California.Data
Applicant .
NOTICE TO APPLICANT:IL after making this Cenifica a of Exemption,you should
become subject to the Worker's Compcwtion previsions of We Labor Code,you must
.JO forthwith comply with such provisions or this permit shall W deemed revered.
Z" CONSTRUCTION LENDING AGENCY
herN
F l for which
Mattherei isaco.uuctiDlending agency forme performance of
Le work for which Nis permit is issued(Sec.J097,Civ.CJ
aQ Lender'sName
] z Lcndcr's Add..
U Q 1 certify mat 1 have read ibis application and ma matte above information is '-
wF correct.I agree to comply with all city and county UNlNnaa and stale laws relating to t
QU building commuction,and heahy eulhnrim rcpentounives of ria city to diner upon the
4I shove-mentioned property for inspection purposes.
(We)agree m saw.indemnify and keep hamnless me City of Cupcnino al
fA Iiabilitiea,judgmcnts,costs and cxpcoscs which may in any way accrue against said City.
U 7 in consequcnee of the granting of this permit. I/
r1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. ,Z_/8—G}
9
Si of ppRc
C, p 11" ,, ` vO > Re-roofs
HAZARDOUS MATERIALS DISCLOSURE as Type of Roof
Will the applicant or future building occupant store or handle ha.rdous material
I
defrad by Ile Cupertino Municipal Code,Chapter 1.11,and the 11.111 and Safely
c,Section 255324)?
❑Yer 56. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cath ha.rdous air contaminants te defined by the Bay Area Air Quality Management .all new materials for Inspection.
District?
❑Yes 9No
I have reed the hureodnus materials requircmenu under Chapter fi.95 a Califor-
niaHcalm&Safay C,le,Sec6ons25505,25533.d25534.1uedcm that ifmc Wilding
thea not currently bout a anent,mat it is my rcaponsiM1ility m notify th
not of the
requirements which must W met poor to issuance of a Cenifcaa of One Signature of Applicant Date
ql-,,13,,P�i — — tl
` 'crorauthorizedagent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE J3Gp-062
CUPEkTINO PERMIT APPLICATION FORM
APN# yJ s
Date:
Q'o 4
2 - / S - o3
Building Address:
2-Z-e?o9 ocz,4G
Owner's Name: Phone#:
e b Ap
Contractor: Phone: License#:
-< r -h 0,6) 377 -47 7q75
Contact: Phone: Cupertino Business License #:
1z c-43 17 -errtir ft- &H 6 `j •LI-/o7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
S r4ie;)- ^-,vr er L,r e G e r doT
Residential R1 Commercial ❑
• Cost of Projecj�
WW l6 �
QtY• �
A li le Fee ID Fee Descri tion 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
•