05110048 CITY OF CUPERTINO '^ ' `��'•''"'r '
BUILDING DIVISION PERMITCONTRAGTORINFORMATIQN
BUILDING ADDRESS: NATIONAL ROOTER PEnMITND,05110048
21732 OLIVE AVE # 21734
OWNER'S NAME: PQtMR ISSUE DATE
ALBERTO DEL VALLE 2911 MONROE ST. 11 /09/2005
NE: SANITARY NO. CONTROL NO.
(408) 241-0887
BUILDING PERMIT INFO
ARCHTfER/ENGINEER: 'BLDG ELECT PLUMB MECH
lop LICENSED CONTRACTOR'S DECLARATION IObDeSCr UOn
-.5 1 hereby affirm chat 1 am licensed under pmritims of Chapter 9(mmmcrcing
with
I)
iN Section TIXgB or Diehion 3 of Ne Buvnea and Rof"Wed Code.and my license is
- „ mrillfoneandercx ._3� a 76 D INSTALL PROPERTY LINE CIO '
3�Z Lionce Class
�h,� Dale Cantracmr,
ARCHR DECLARATION
f W V I understand my plho used shall fx uud u Public records /f "
C uo G Lkeued Prof cssianal
5 OWNER-BUILDER DECLARATION RV/!' iu1Af
a(
M I hcmby affirm that I am exmpt foam use Contactors License law for etc {/
o O following action.(Section?831.5,Buslrcss and Professions Cade:Any city or county $1500
3 @ ff which requires a Permit b construct.aim
xc improve,deolish,m.pots any sticture t.
-z< prior b its usuanm.alsu requires the applicant forsuch permit in files signed amcomin
bC Ls]iMc pummttomepmiaimunfdeconl W$Li==Uw(CMa 9 Sq.Ft. Floor Area �/�/{Val_4ation
e1-0 (commencing with Section 7000)of Division 3 ofex Business and Precisions Cono)or V
_ that he is exempt tMmfrom and the bub fed the alleged exmpeon.Any violation of
Section 7031.5 by any Applicant for a permit subjects the applicant b a Civil penalty of Z,Anil MAHer U U Occupancy Type
not mom ban fico hundred dollars 15500).
1,u Owher of the pmpnty,or my=ployca with wages u thch mle compenxdon,
will dadxwmk,Codex he Cor boor intendede Law
does WE apply TD move,
of Required Inspections
and property
wh au Cade:The Correctors nd whe law doss not apply lf rt e ugh q P
Own eny who builds or ice pmvu tix moq and who Asea auch wort Mmxl f edthrough his
.
awn employees.er.the
Wiprovided Nor such improvements art nor intended c moaered ror sola comer..
builder be building buimprovementbheldwithinarc/ear mf improvefo.theoseof
builder will have the buNrm or proving tMt he did not build m improve far purpose of
sale.).
1,as awher of be property am moduvve,ly cO.uxtin&with licensed conuxtars to
construct the project(Sec 7044.Business and Professions Code:)The Conuactmrs Li.
onse law does mor apply An an owher of pmpenywho builds m improves Ocoma.and,
whoconuxts for such pmjcm with aconuslor(s)licensed pursuant b be Contrrebh
License Law.
❑lam uempt under See .Bh PcforthiamCon
water Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury am of the following dedarWmu
1 haw and will maintain a Certificate of Concent re xlf-insun:fa Wasters Compen-
sWon,As provided for by Section 3700 oar der labor Code.for the peefunnan.of On
work for which this permit is issued
❑1 have and will maintain Workers Compeadmon Insurance,As acquired by Section
3700.f the LAW,Cade,for 0."farmance of be wort for which this permit is issued
My worke
r's Compensation Iwnme fartier and Policy number am:
camas.hkiy[ trp./7f."r!Polity N..: &.)S A-r/M Ic-121 P/-2]O 01
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ods healon head not keorri if the Permit Is for one hundred dollars($100)
oarless)
I Certify that in the pnfonnanno of be work for which bis Permit u issued.I.bail am
employ any permn in any mwnerx C b become xbkcr to the Worked Compensation
Laws of California.Dax
Appliant
NOTICE TO APPLICANT:If,arts making this Ccnifax of Exemption,you should
bccnme subjttt to the Worker's Compemadon provisions of be Labor Code,you must
.J z TaMwith comply with such provisions or this permit shall be domed rooked.
?O CONSTRUCTION LENDING AGENCY
1 hereby affirm eco ft.1'.co strOctim[coding agercy for the,Parurmance of
Ri > six work fur whim this Permit is caused(Sec.309'f,Civ.C.)
[t10 LcnEces Name
= z Undeh Address
U0 I onlfy Out I have read this Application and state than ex above infcnnaeun is
[7. ^ conett 1 agree b comply with all city and county onlinahees te and some laws relating b
p SV" building concoction.and hereby authorim mpromeadw of bb city to enter upon be
r E above-mcneoned property for inspection puryaaes
(We)agree to taw,indcmmfy and limp hanmless the City of Cupertino against
o-F•t h liabilities.judgmcnacests and expenses which may in any way we=against sand City
U z PLICAPPLNT UNDe of the ERSTANDS roming of AND WILL COMPLY WITH ALL NON-POINT Issued by: Date IK-3j-dr
SOURPEGULATIO
` zee" /� -ate Re-roofs
muaf , 4
Si tart of 1 Can cbr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ex applicant or future Wilding aceupant Com orhuodk hi arduus material
All
dcfncd by ft,
e Cupenlnu Municipal Code.Chapter 9.12,and de,Health and Safety
adc.SEly.25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya ON.
Will tlx applicant or future building occupant use equipment or*view which If a roof is installed without first obtaining an inspection,I agree to remove
mit hmaNnus air contaminants As dcfned by ex Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
1 have mail the hvaNws materiab rtquirtmew under ChePterd95 affix Califor-
nia Hcslbk Wchycede,Sceyw 25505.755]]tad 21534.1 undcrnaM eutifdx building
docs not cotcney haw a tencnt,that it b my mspomibility b notify be occupant Of six
myvi nu hich muss met psi issumcc
I.Cemfiate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B"or better
2 e,mmOMimd agent Date'
Community Development
J 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
,, 1 5 62 0 � Os /roaLe
OWNER'S NAME: /;?,p/ PHONE #yog io s/
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:Z�2 //- 9—CDS—
Signature Date
Please check applicable subcontractors and complete the following 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
Owner/Contractor Signature Date
allu
CITY OF CUPERTINO RREPIPE/SEWERS/MAIN SERVICE
,CUPEQj1NO PERMIT APPLICATION FORM
APN # 3 Date:
Building Address: ;21/rJ3
1�2- 1-7,30,
Own r' Name: Phone#:
2 s-z-
Contra or: Phone: License#:
M02 76?LEOO
Contact: Phone: Cupertino Business License#:
`109- -z y1-0,y8
Building Permit Info:
Bldg X Elect ❑ Plumb F3
Job Description:
Residential Commercial ❑
Cost of Project:
o�
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 Repi e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING