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04080250I L CITY OF CUPERTINO "BUILDING s�v `"" x47777 F a r< �4� NPdAM DIVISION PERMIT 4 -DRAIN BUILDING ADDRESS: 0173 PARISH PT DOCTOR PERMIT NO) 4 O S O Z SO OWNER'S NAME: PERMIT ISSUE DATE DONALD ONE: SANITARY NO. CONTROL N0. 0 ARCHITECffENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description I Wreby affirm that 1 am licensed. under provisions of Chapter 9 (commencing P with Section 70(X1) of Division 3 of the Business atM Professions Code. and my license is in mu force and effect.WATER HEATER REPLA Lkenm Clsss Lw X Data Contractor ADDRESS CORRECTED- R. GAVEWRONG ARCHRECrS DECLARATION 1 understand my plans.hall W cost ss public records 09/01/04 SEP Z 2004 Licensed Professional OWNER -BUILDER DECLARATION License Law for the I hnam sine oat I am exempt (rum the Cssions - Co city sur county massa. (Section ID3 r. Business moPtofeviwn Code: demolish. m repair any shement whichwhich requires a pctmil to mantises(, eller, improve, minor which re s h Per t poor in its issuance,rsu nt to teIW applicant tforhe Cohpermittortessigned Chmmcm that he is licensed pursuant the provisions of the Connector's License law (Chapter Sq. Ft. Floor Area aluation (commncing with Snction nand) of Division 3 the Business end Code) or the on. An vi that two is esmnpl therefrom and the base fm the alleged exemption. Any violation of -$500 Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of APN Number Occupancy Type P y 'its]P not mom than love hundred dollars (5500). ❑ 1, as owner of the property, or my employee with wages as their sole compensation, will do the work end damnation is mainlended oraRered Wide (Sec. 7044, Business Required Inspections and Profession. Code: Tha Comnctofs License Law dean act apply to an owner of property who bul Itis or improves thereon, end who does such work himuH or through his own employees, provided Chet such improvements art not intended oroBered for We. if, however. the Wilding or improvement is mid within one year of completion, the owmr- builder will have the burden of proving that he did not Wild or improve for purpose of tile.). ❑ 1, as owner of the progeny, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Bondman and Professions Cade:) The Contractor's Li - scree law docs not apply to an owner of property who Wilds or improve thereon, and, who Connects for such projects with a contramr(s) licensed penman, in the ComnaMore License Law. ❑ I am esempt under Sec. 8 d: P C for this mason Owner Dem WORKER'S COMPENSATION DECLARATION I hereby aRlm under penally of perjury one of the following declarations: I have and will reainuin a Certificate of Consent to self -Insure for WinkefsConsists. sation, m provided for by Section 3700 of the Labor Code. for the performamc of the work for which this permit is issued ❑ I have and will maintain Worker's Compensation Insurance, an mquimd by Section 37W of the Labor Code. for the performance of the work for which this permit is issued. My Workers Compensation Immmen carrier and Policy number am: Carrier. Policy No,: _ CERTIFICATE OFEXEMPrION FROM WORKERS' COMPENSATION INSURANCE (Thisseetion need not W complcwd !film permit isforom hundred dollars (SIM) M Ices.) I certify out in the performance of the work for which this permit is ismad, I .hJl not employ any person in any manner so an to become subject to the Workcrs' Compensation Laws of Califomie. Date Appli ant NOTICE TO APPLICANT: If. alar making this Cenificam of Exemption, you should become subject w the Worker. Compewsation provisions of the labor Code, you most forthwith comply with such provisions or this Norml shall be deemed revoked, CONSTRUCDON LENDING AGENCY I hereby affirm that then is a construcdnn lending agency for the performance of the work for which this permit In issued (Sow. 31197, Civ. CJ Lender's Name lander'. Md. 1 coolly that I have read this application and sate that the aWvc information is correct. I agree to comply with all city and county oNinamca and sum laws mating in building construction. and hereby authorize mpresenmivm of this city to enact upon the above-mentioned properly for inspecden purymea (We) agree to ave, indemnify and keep harmless the City of Cupertino against liabilifies, judgments, costs and expenses which may in any way memo against said City in consequence of the Spending of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date " SOURCE REGULATIONS, Re -roofs Type of Roof Dee HAZARDOUS HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future occupeartstem handle hue t nmaarial 9.1or m defined by the Cupertino Municipal Code. Chapar 9.13, and the Health and Safely Code, section 25532(x)? All roofs shall be inspected to any roofing being installed. E] Yen ❑Nu prior material If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which Will haurdous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. Dislike? ❑sen ❑No I hrvc mad the huardts arnatorialsrequireencnes under Chapmr 695of the Califon ria Health& Safely Code, Secticm 8505,25533 and 25534. I undersand thatifthc Wilding Own not c menty have a atom. Nat it n my responsibility to notify On occupant of the ' requiremewu which must he met prior to income. or a C.Nrcam or occupancy. Signature Of Applicant Date All roof coverings to be Class "B" or better owner or moorivad agent ma CITY OF CUPERTINO .BUILDING DIVISION PERMIT 'jCQNTRACTORINPOA%l At t ONS ,`. BUILDING ADDRESS: PERMIT NO. DRAIN DOCTOR 04080250 Oi1Vq-Z'S*AMEk'AX16hPERMIT ISSUE DATE NE: SANITARY OL NO. ARCHITECrfENGINEER: — BUILDING PERMIT INFO BLDG ELP.Cr PLUMB MECH O O O 7p LICENSED CONTRACTOR'S DECLARATION Job Description I Mosby affirm m lamed 1 am under provision of Chapter 9 (commencing p IMS 70)(0af Division 3afne Buaiov en Professhms Cade, endmylicenw is in full ffin full f and ' `i gz Lieawclau Us. g WATER HEATER REPLACEMENT e Contact" anuw r [ ITECI'S DE ATI L a3 I understand my plana shall bt used a public recons Licensed Professional OWNER -BUILDER DECLARATION a1 hereby .(firm the 11. exempt from the Lienee Lew for she b o following report. (Section 7031.5. Busincr. and rmahms Co i Any city ar county ' $ ols h. or which mquima a permit to nae. de pair any twcwm L aloe cat fwve. deermitt �y primmiuissuance. mires b fie sof for suchpermiuoflaw La (Catemcm uantto a be he ensedpalso Sq. Ft. Floor Area Valuati �o - $ t.- (that commencingwdpuntion7shcprovisistoOof eBuebrinianwlaw(ComcrY (cat he Is log with analw s KKMand f basisof rmNC egeincss.nd Prooreson. An is l Come) or that he ts exempt dercfwm and the baa for the alleged ewmpdon. Any Walauon of Section 7051.5 by any Applicant fon permit subjccu the applicant In a civil family of 1Yj5 mer Occupancy anC Type nut a. Nan five hundred doliona M10). 3 jj lbi}LI QIz 0 0 1, as owner of the property, m my employees with wages as their sale compensation, will do the work cad to structure is not Intended car.Rend rot sale (Sec. 704, Business Required Inspections and Pro..I.. Cade: The Canumme. License, law dam not apply b an owner of property who builds or improves doemon, and who dos such wart himself or through his ownemployms, provided that such Improvements ase nothmoded oroRered forple, if, , however. Ne building or Improvement Is sold within one year of completion, the Owncn builder will have the human of proving that he did not build or improve for purpose of plc.). ❑ 1. as owner of the property em eulmivcly contracting with Ilansed contractors to construct dw pm)ect (Sec. 784. Business and Pwres9aN Cade:) The Co eracbfa LL cave law does not apply in an owner of property who Wit& or improves thewon, and who contracts for such projects with a antracter(s) licensed pursuant in Me Convector's License Law. , ❑ 1 em exempt under Sec. . B h P C for this wean Owner Data COMPENSAi70N DECLARATION 1 hereby affirm under penally of perjury one of the following declensions: I haw and will maintain aCcofiate of Consent to self-Ivum for Workers Compen. ion. as provided for by Section 5700 of the Mbar Code, for the performance of the IC173WORKERS rk for which this permit is issued. 1 have and will maintain Workefs Compensation Insurance, as required by Section Wof Ne labor Code, for Ne perrmmana of the work for which this permit is issued. y Wgrkcr's Cnm nation Inwreta carrierand Policy nA 1Aver 3 Palle a.: v1 CERTIFI C MPENX MON WORKERS' I fff///��� COMPENSATION INS ANCE (Th6wction need not bt completed irthe faunas is fmrane hundred dollars ($]M) car las.) I amity the in the perfmmana of the work for which dols permit u lamed. I shill not employ any person in nay manner an u to become sub*, to the Watins Compandon Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making Nis Certificate of Exemption, you should become subject to the worke s compensation provisions or to lobe Code, you moa forthwith amply win such provisivv Or Nis permcommit itshall Ec dorcwked. O CONSTRUCTION LENDING AGENCY I hereby affrm net nen its constitution lending gang for the performance of Q the wort fur which cab Permit is added (Sec. 5097, Civ. C.) 1 -maces Name z Lender's Address Q I modify that 1 haw rad dols application and sum that rte now Information is inas and tum laws relating nca 1 bra m amply win all city and county omneb building construction, and hereby mMOdre mpresenmiws of this city to enter upon rte aavo-mentioned property for inspection purposes. y (We) agree to saw, indemnify and keep h uradets the City of Cupertino against fp liabilities, jddgmrnu.cmu and minces which may in any wg sant.gains and City z in announce of rte granting of this form it. ^ APPLICANT U 'DERSTAf DS ND.WILL COMPLY WITH ALL -POINT SOURCERE L O _ Issued by: Dat e -roofs Z ��� ( SjgrofApplhoffRaComonclor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or town building occupant store or handle haeardous metrial as defined by the Cupamo Municipal Cade. Chapter 9. 12. and the Health and Safety Codc.S cdon35553(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes iV Nu If a roof is installed without first obtaining an inspection, I agree to remove Will dot applicant or future building Occupant use equipment or devices which it havamous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. imriv7 [D Yes Nu I haw mad de haamnusmemdets reyuirtmcnv un de Cha pter6.95oftieCaIitor- nuHcalnhSdaty Catle, Sectiom25505.35557 am12555d. 1 dcrsundthat if the lailding deed e n t it tr m b nadfy de nYupNt of rte rm �h cc orLiicco mquircmc t hwl myth atpd (donee afacm of afylpycy,o/ Signature of Applicant Date (Ol ((Dow "B" All roof coverings to be Class or better Ower or aunvdmd agent �J CITY OF UPEkTIN0 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: I a. ( � 3 f w— Pt I's -0 l y PERMIT # I ori oz T -a OWNER'S NAME: �n k K 's I„v-, S I A ,-r,,r PHO 4-10g) '3-70 —.3uv GENERAL CONTRACTOR: I J I am not using any subcontractors: Y` 3 0 /01-1 Signature Date Please check applicable subcontractors and complete the following infnrmatinn- Tyalter/Contractor Signature 3� Date 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 Q o cl-bt f J o ti n Roofing Septic Tank Sheet Metal Sheet Rock Tile Tyalter/Contractor Signature 3� Date 11 CITY OF CUPEkTINO CITY OF CUPERTINO WATER HEATER Z S' o PERMIT APPLICATION FORM APN # 3[/ 4 l 6 I T Water Heater / Vent Date: PPERMITFEE Building Ad ss: v r q3 fa.NC,6k (9l- Ot5-0 f 1/ BENERGY Energy Owner's Nie: � „�� Dev i A ce" 12, i Phone #: BUILDING Contractor: , &rk�n ocfvt. Tokh 5 �U 1� Phone: 3?� Licenset L 6 / 3 Contact: U Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb 2-1-� Mech ❑ Job Descriptiory� v CA a e, wCt kr Ct I Residential Commercial ❑ Cost of Project: Strapped M On tlatform El New Location ❑ Replacement ❑ Bonded ❑ T ouiicl� Fee ID Fee i)eccrintinn Far r7rnnn BPWHEATER Water Heater / Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING