04080232 if
CITY OF CU
m " t '' `° '
BUILDING DIVISION PERMIT ` Ct1lI -C'TQ�t•IN1'C7t tT1AN
BUILDING ADDRESS: TOM' S PLUMBING PERMIT NO.04O80232
DISE ]DR.
OWE:OWNER'S NAMPERMITLSSUEDATE
JOHN PRE= 1994r qAPA'rQCA 21ZW�PIXil R;) Q2 C 12004
NE:
SANITARY O. CONTROL NO.
(408) 867-6010
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOo LICENSED CONTRACTOR'S DECLARATION
uF I hereby affirm that l am licensed under provisions ofChapmr 9(commencing Job Description
nm`aj with Section 700(y).!Division Softhe Busineasand No(..case Code,and my license is
a in full forte and art, 2�
LicenseClasa C'--,7F`L*.a REPLACE WATER SERVICE /
Y9 F,D Dam ARCHITECTS DEC r O I A.
z$ 1 undersand my plana shell ha mml u push m rarnNi
it
5 jet Licensed Pormom...I I,
g OWNER-BUILDER DECLARATION 9�
<I 1 hereby.('fere on I I.S.exempt from Ne DanlmclCo License Law for the
my
00 following recon.Permit
lit 7o3trBusincsa and ova,demolish.
Code Any city or county
a'$�i which requires a permit re contract,alcor,improve,demolish,m repair any swmum
�y cpnor h.,he its issuance.momenalso t to
do,applicantof forsucth.C.hpermil micese Lawdnammcm
i< < that me licenseditpumtion7 h)provisions of theContramers ndProfLaw(Chopmr9 Sq.Ft.Floor Area Valuation
tzG chat he
oomptccasion and the
n3 ofthc.gad Boomers and Professions of
that he u Bumps therefrom end the hula for the alleged cumpdon.My violation of '
Section 7031.5 by any applicant for a permit subjects me applicants o a civil Penalty of 3 A9111 2iiier 0 0 Occupancy e
te N
not moan five hundred daltons($5007. P y TYP
❑1,u owner of the pmperty,.r my employees with wages m Heir sole compenadon,
will do thework end the swmurt is not intended m offered f oxale(Sec.71740,Business
and Professions Code:Tim Conuumr's License Law does not apply m an owner of Required Inspections
propeny who builds.improves thereon,and who deco a tach work himul f ver through his
own employees,provided Nat such improvements ea not intended oroRered form*.if.
however,the building or improvement is sold within one year of completion,the owner.
builder will hats this burden of proving that he did not build or improve for purpose of
to).
❑1,as owner of the property,am exclusively contracting with licensed contractors;to
constmcl the project(Sec.7614.Business and Professions Cade:)The Conuacmr's Li-
cave Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such pmjens with a contractor(s)licensed pumuanl to the Contrulor's
License Law.
❑Ism exempt under Sec. ,B&PCiorthismuon
Owner - Dale
WORKER'S COMPENSATION DECLARATION
I hereby aRrrn under Penalty of perjury,one of the following declonations:
1 ban and will maintain a Certificam of Consent to self-insum for Workers Compen. -
salion,a provided for by Section 37W.f the labor Code,for the performance of the
work far which this permit is issued.
d have and will maintain Workcri Compensation Insurance.as uquired by Section
37W of the tab.Cade,for Ne performance of the work for which this permit is Wood,
My W.*cls Compensation Insurance carrier and Policy number art: t�
Carries FtLLstiO"�—' Policy No.: I 1^'t l.-7
C TIFICA.R�FTION FROM WORKERS'
COMPENSATION INSURANCE
(Th*sectiost need notboc.mpl.md if the Turnallis faro..hundred do]Ws($100)
nr less)
1 certify that in the performance of the work f.which this Permit is issued.[she[]not
employ any parson in any manner so a to become subject o the Workerd Compenadon
Laws of Califomia.Data
it
NOTICE PPLI ANT:r'ofter Compensation
this Certificate of of Exemption,you thou*
.J Qbecome eon t m the Worker's Coo s at this previsions of Ne Labor Code,you run
forthwith comply with such provisions at this permit shall be ticcmcd revoked.
.Z.t 51CONSTRUCTION LENDING AGENCY
E~ Iherchy.M.Nat Nem is acanstruninn lending agency for me performance of
Q'tNe work for which this permit is issued(Sac.3W7,Civ.C.)
WA Lender's Name
0. z Lender's Address
U Q 1 minify chat I have mad this application and scam that the above Information is '
ty F coven.I&gone m comply with all city and county ordinances and stale laws misting to
0U building contraction,and hereby southern representativm of this city to enter upon tic
r W anave-man0.ned property for inspection purposes.
(We)agree m ave,indemnify and keep harmless,the City of Cupertino against
aFs y liabilities,judgments.costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
e. .r.X M . � P'tb�1 Re-roofs
Sifurs VApplicarriOCantractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliecm ver Road building occupant slam or handle ha'rsrdous material
az definetl by lha Cupertino Municipal Code.Chapter 9.12.and tha Nca1N and Safety
sae.Seed.zs53z(an All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Nu
Will the applicant or future building Occupant use equipments devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
it hayardous air conmminants our defined by the Bay Area Air Quality Management all new materials for inspection.
7ucDistrici?
❑Yes 06No
I have mad the huaNnus mom mis rcquirememunder Chapter 6.95 of Ne Califor-
Heolth&SafelyCode,Sccdom8505.8533mdM534,lunacmmndNmifthc building
snotcure.dy have atenant,NmitismymapomihilitymnodlNy .occupantofthe
uirements which must be mm peorlui cc of.CenillemeOf &pane. Signature of Applicant Date
2
Owcar oath 'zed agent DOE All roof coverings to be Class"B"or better
'
x x Community Development
10300 Torre Avenue
j Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
t
PEI�TINO
Building Department
JOB ADDRESS: PERNtW#
104 Z A,, Dkt- b
D Z
OWNER'S NAME: PHONT14 _ o
GENERAL CONTRACTOR: 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
v- Plumbingf 9
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
A 4 /9
,L M dam/
Nwner/Contractor Signature Date
CITY OF CUPERTINO 66P6 22 2
REPIPE/SEWERS/MAIN SERVICE U .
• CUPEkTINO PERMIT APPLICATION FORM
APN# 3 1 0 o2- Date
Building AJddress: nn
Owner's Name: Phone#:
13'04A/ jre& C1, -)— 6 05-V--
Contractor:
5'YContractor: Phone: License#:
.
o ,s ,
Contact: Phone: Cupertino Business License#:
1z"
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential �J Commercial ❑
Costof P ject: _J�,
Qt
A 1' able Fee ID Fee Description 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
20 � rJ �
7 ��