05050050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTQR INFORMATIa1 U
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BUILDING ADDRESS: PERMIT NO.
KEISER, ROSS GENER CONTR 05050050
422 Al-7
OW NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY Q&kOL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION Job Descri TwD
t¢y I bureby,Klan Nn 1 am of
Bu under provisions of Chafer n(mmmense is Pp-- ALE®
n< with Section 70M llto.afro Divitlon3af theBuaineuWProftsdou Code,andmylicenae is '11'F
ppppp< in full farce eM eRett
z License Class Lk.N BREAK HOLE IN POOL & BACK I
Dale ContractoTSDECr
9 ARCHITECTS DECLARATION
all 1 undersand my plans shall M used as public records
/ 1005
1�
c Licensed Professional
is
OWNER-BUILDER DECLARATION ulL®'
I hereby pRrm Nn t m exempt from the afa License 4w for the
EUO following moon.(Section 703 I.S.Business and Professions Code:Any city or County
which requires,a permit W construct,a)ar.improve,demolish.or repair my structure
_Z prior out its issuance.also requires the applicant for such permit to rile a signed statement
< put hers licensed p...ntmNeprovisions ofNeContractoriLlmns, aw(Ch.Pla9 Sq.Ft. Floor Area Valuat on
(commencing with Section 7000)of Division 3 of the Business and Profession,Cook)at
Nat he Is exempt therefrom and the basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applkauu•civil penalty of3 r �erO 0 Occupancy Type
not mom than live hundred dollar(3500).
❑I,Mo Ofthepmpmy.wmywplayceswhhnguuftkwlecampenuuon,
and dothewom,ande:TheCreuominaMedoraw door apply
Bunrof Required Inspections
p. Professions Code:The Cantereon.and
w -taw don rot appy lf t Owner is q P
propertywyebuildsorinsproteach Improvements
doessuchwork endehimalf dthrough his
awnemployees,provided Imp no
Improvementsart out our Ofo oronemd fmWs,IL
builder.the buildingorimprowmmtIshathwithinore Seer of mprove for
Nepse of
"Ic.). will haw the burden of proving Nu he dM not Wlid or improv far puryolo of
tile.),
C 1.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Profasiam Code)The Contractor,U.
cents law docs not apply no an owner of property who builds or improves Norton,and,
who cumsacu for such project with a contraWrO)licensed pursuant to the Convector's
License Law.
❑Ian tempt under Seo. .B&P C fox this recon
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby&Rou under penalty of perjury ane of the following declarations:
1 W w and will munuin a CW M1mlo of Conant mulf-Insure for Wmlece.Compcm
1031(0
tian,u provided for by Section 3700 of the Labor Code,for Ne performance of the
rk for which this permit is issued.
1 Mw and will maintain Workeri Compensation Wurace,u requited by Section
of the labor Conic,far the performance of the work far which this permit is Issued.
y Workee,Compensation Inharame rain and Policy number art:
rner. Polity No.:
CERTIFICATE OF EKEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(76lseectiru need notMeompleted If the permit is fmanchundred dollars($)00)
or leu.)
I coolly Not in the performance of the work for which this permit Is issued.I shall not
employ any person in any manner an as to become subject a tits Workers'Compensation
laws of Califon Dam
Applicant / v C c -i°1 !
NOTICE TO PPUCANT:If,afar making thin Ccnifium of Exemption.you should
become subject to the Worku's Compensation provisions of the ebur Code,you muss '
.JO forthwith comply with such provisions or this permit 0111 be dmmod rooked.
? tiCONSTRUCTION LENDING AGENCY
[r (hereby To.dot there Is a comuctino lending agency for f perfurmnnce of
C tits work for which this permit ts issued(Sec.3097,civ.C.)
W� 0 Lender's Name .
r7 z Lender's Addae,
t.7 Q 1 certify that 1 haw read this application and sum that the above Information is
LL Hcorrect.I agree W comply with all city and county ordinances and sum laws mlating in
Q}U building construction.and hereby author=mprcxmadves ofthu city W color upon the
F W ,buve-nomuoned property far inspections
an Purpose
G (We)agree to now.indemnify ad keep humkw the City of Cupertino against
l/) Iiehilluu,judgments.tasu adtapensa which may in an,ray accrue against said City
(„) In consequence of the growing of this permit.
APPLICA NDERSTANDS ANTI WILL COMPLY WITH ALL NO -POINT Issued by: Date
SOU ULATIONS.
Re-roofs
Slimpture of ApplicaVCantrutor P—Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Wt applicant or future building aecuponname or handle husrdoua material
a 111 d by the CupeNno Municipal Code.Chapter 9.12.and the Health and Safety
Cade,Soetian 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
1docsCYa ON.
Will the applicant or futum Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvadoas air conuminanu u defined by the Bay Area Air Quality Management - all new materials for Inspection.
mo%!cuK=ndyhm
Wlct7
Oyu
1 hew mad the hmadnmmatcHats mquimments under Chaptcr6.95 arthe Califor.
Health tit Safety Code Sections 25515,15533 uu125534.1 undcuWnd thetlfthe building
lona4Nath 6 my rat u ilily W on l'y the occupant oyulrtmbumetplgLwivua actrtirlo.aorampa Signature of Applicant Date
Owner euthorbm agent m: All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�Ry p Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
Z2 .3Z 90 � bSos�os�b
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: ZOStr FAX#
I am not using any subcontractors:
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
CITY OF CUPERTINO
DEMO v S'`C>
1� CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
2f 7- )2 z-Al
Owner's N e: / Phone#:
C rbe'
Contractor: I License#:
I C J' 6 4 ,O�a e4p, -?O Yg7�
Contact: S, M Phone: _ • 9 g O��
Applicant/Contractor: ,
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: r/jam ri/
Residential: 04 iy p Commercial:
Sq.Ft. Floor Area: 01 $/Sq.Ft.:
Architect/Engineer: Valuation: GC.
OoD
• Type of Construction: Occupancy roup:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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