03070020z
z O
N
a>_
L1r 0
UO
OU
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
" CONTRACTOR INFORMATION�`p;.
BUILDING ADDRESS:
BAY AREA REPIPES
PERMIT NO 03070020
OWNER'S NAME:
1561 ORANGE GROVE DR.
PERMITISSUEDAT9
9NE:
(408) 371-5763
SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER:
BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
hereby Chapter 9
Job Description
P
1 affirm that I am license u cr provisions of (commencing
Sancti 1 B Division 3 NCB
Professions Coda,! my license isin
'
wish of or u and
Llcenl fn_ �I Li cX
�p�
REPIPE/WATER SERVICE 0=1PJAIa E.�
Da Cunl r
ARCHITECT CLARATION
I understand my plans shall W madas public records
JUL f1`2003
Licensed Profcssianal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law fur the
61v1 ®Ig�g^
1L
BUILDING
fullowing so
rean. (Section 7131.5. Business and Professions Com: Any city or county
W
which requires a Pavan to cansuuct, atter, improve, demolish, or repair any structure
non
prim to its issuance. also requires the applicant forsuch permit to file a signed statement
that he is licensed pursuant o the provisions of the Conmclurf License Law (Chapter 9
Sq. FL Floor Area
Valuation
(Commencing with Section 7") of Division 3 of the Businm and Professions Code) or
Not he is exempt therefrom and the basis for the alleged exemption. Any violation of
32619107.00
'APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
I, as owner of the property, or my employees with wages As their wit compensation,
_
c
will do the work. and the structure is not intended or offered for sale SCC. TON, Business
and Pmfeuinns Carlo : The Comractor's License Law data not apply to an owner of
property who builds or impro e.thereon,rod who doessuch work himselfor through his
502 — FINAL PLUMB I ENERGY
awn employees, provided that such improvements are not intended or offered for sale. If.
507 — FINAL PLUMBING
however, to building or improvement is won within ane year of completion. Ne owner•
builder will haw tha burden of proving that he did not build or improve for purpose of
,.I. I.
❑ h as owner of the property, am exclusively contracting with licensed convectors to
Construct the the project (Sec. 701,1, Business and Professions Code:)The Comracmri Li
cave Taw data not apply to an owner of property who builds or moraines themon, and,
who contracts for much projects with a Contractors) licensed pursuant to du Conmcsela
License Law.
❑ 1 am exempt under Sec. . B k P C for this reason
Owner Dau
WORKERS COMPENS0014` DECI RATION
I hereby o(firre under penalty of perjury ane of the following decimations:
-
I haw and will maintain a Cenificate of Consent ulr.insum for Worker's Compcm
cation, ns provided for by Section 3701 of use Labor Code, for the performance of the
wmit for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurance. u required by Section
100
3o(Nc lobar Code, for the perormancc ver thework fm which this permit is iumd.
My Workers am ovation Insurance carrier and Policy numherme
C 'e _Polity No.22 OZ. WI
CERTIFICATE OFEXEMPr10NI RKERS' !-4
COMPENSATION INS CE
(This section neAd nmhecamplered if the permit is far mu hundmd call. (SIOB
,it less.)
I certify Nat in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so an or become subject to the Workeri Compcnudon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Ccnilicale of Exemption, you should
hecome subject to the Worker's Compcnsalion provisions of the lahnr Code. you must
forthwith comply with such provisions or this permit shall an deemed invoked,
CONSTRUCTION LENDING AGENCY
I hereby a0rm that d¢re iso comlmctinn lending agency for lac perfurmmcc or
than work (ter which this permit Is issued (Sac. 3057, Civ. C.)
Lendels Name
_
Underi Address
I cenify that I have mad this application cad sate that the above information is
Correct. 129MC 10 Comply With all city and county ordinances and sate laws muting to
building construction, and hereby initiation rtpresenwiwa of this city to enter upon the
above-mentioned progeny for inspection purposes.
(We) agree in new, indemnify and keep harmless the City of Cupertino against
liabilitiu, judgments, costs and expenses which may in any way metric against said City
in consequence of the granting of this permit.
APPLICA14T UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: - Date
5 URC EG ONS.
2
Re -roofs
Type of Roof
rJaIre of ApplicantlConmctor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oCCupwt note m handle havuduns material
az def ned by the Curs nino Code, Chapter 9.12, and the Health and Safety
Mcipal
cue. Stmmn 25532(.)7
Year Na
All roofs shall be inspected prior to an roofing material being Installed.
P P Y g g
❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant vee equipment or devices which
Il havardnus airconaminanA dcrined by the Bay Area Air Quality Management
all new materials for inspection.
mica?
,Yen Nu
1 have mad the h imams maurialsrequ a mcnts under Chapter 6.95 of the Cmifan
nim Hcslth k SafetyCadc, Sections 25505.35533 wd2 534.1 unMmwd thw ifthan building
docs not currently how a tenant, Not it is my responsibility m nn the occupant of the
��9�9u/t�mmen which� IbCmel� donoissuwceofacerdfi—caw cu
Signature of Applicant Date
7or
YVro�
All roof coverings to be Class "B" or better
g
defB�Ihorircd
in4
gcm a�
Cl
•
aITYOF
CUPEkTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
o3D7oaZo
APN #/
O
Date:
-Z d3
Bu1din Address: U et U.J
Re i e of Fixtures
PLUMBING
Owne s, Name:
JpAx Awe
Bldg. Permit Fees
BUILDING
Phone #:
ZSZ — Sig
Cntractor:
M AewA R
Phone:
8- 71-S763
License #:
empfte861931,
Ctk t:
Phone:
Cupertino Business License #:
h S-?-Y�Ne)
zDI- 763
23773
B ild' t Info:
PLUMBING
BUSLIC
B dg Elect ❑
Pl mb
Jo tion:
1 C.�-irY Ss1rU � �
Residential -
ercial ❑
Cost of Pr ect: 5 TT
Qty. if
ADDliczble Fee ID
Fee Descrintion
Fee Groun
/ PPERMUFEE
PlumbingPermit 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
22366
��, 93