05020137 CITYOFCUPERTINO �^ r x ^�>i�•'
BUILDING DIVISION PERMIT NT OT
BUEDING ADDRESS: BAY AREA REPIPES 1E11IT"105020137
OWNER'S NAME: PERMIT ISSUE DATE
MARKSMITH
ONE: SANITARY NO. CONTROL NO.
(408) 371-5763
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ZZ BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION O O O O
EY 1 Mrcby affirm that 1 am thousand under providers o(Clmapser 9(commencing Job Description
who Section 70(10)of Divial3 of0m Business and Professions Code,and my license is
:ai mmnmmeand errem COPPER REPIPE BATH/HALL
S g— License Claes LIc.s1
L Dam Contractor
m�
ARCHITECTS DECLARATION
y 1 understand my plans shall be used as public records
i1el P_t
u. Licensed Professional
='y OWNER-BUILDERexemptTom the Chau ON
arm
.� E 1 hereby affirm that I am exempt from the Contrmmor's License Z.iai-he
O D following mason.(Section 7101.5,Business and Professions Code:Any a(y or county n
$ which mquims a permit m comtmeL alcor,Improve.demnlLN,m mpdr y mumu¢ l- onn
-
�+ prior m its issuance,also requires do applies¢(orsueh pennitmOlc asi Jmuemem
t <
that he is licensedpunuantmNeprovisionsoftiroContmcmreLmcnselaw emgp'l � 'I _Sq.Ft. FloorArea---,,
rCH� Valuation
$ (cmnmendng with Section 70r0)af Divtsion3nf Ne Burimssand Pm2,lmns CmWe) u
Nat he m exempt Ihemfmm and the bum for The alleged exemption.My vloladem or
Section 7011.5 by wry applicant for a permit subjects the applicant m&civil penalty of /1 Occupancy Type
nm more than Jive hundred dolmas 3 et0 0
(5500). 1��/ � 1/ T
❑I.uownerof Nepmpeny,mmyemploymwlNw Wudsbmlecompenudon, I
will do thework,and the ewcurn ianainmadetl waQemd forum(See.f.,Busimasatai /
, ' d Inspections
and Professions Code:The canewemrs license Law dm ant apply to an owner of R9 P
own
property who Wildsoimprowsch improvements
who amaueh womille Ms
own employ¢,provided that weer Improsememts tae net en off moaesed formic.
however,Ne building,thatorimprovementlahalt within one year of completion,theown of /
builder sniff haw dm burden of proving that K did not bW10 m Improve Tor purpose or
um.l.
X1,u owner of sm instantly,am exclusively connecting with licensed mntrumn m
onstmct the Project(See.7044,Business and Profession Code:)The Conlimucr's Li-
cense law coat not apply as an owner orpropeny who Wilda or improves thereon,and
who contracts for such pmjema with a eamrscmr(s)licensed pursuant m the ContnmaYs
License taw.
❑1 am exempt under Sec. B&P C far this memo
Owner Dam
WWORKRIMCOMPENSATFOWDICLARATION - f
1 la eby affirm under penslty of perjury ane of dm fallowing decimations:
I have end will mnintain a Certificate of Consent to self-insure fm WwM'sCompen-
ution,as provided for by Section 3700 of the labor Cole.for the perimmanee of the
work for which this permit is issued.
❑I Mw and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit Is issued.
My Workefa Compensation Insurance canim and Policy number w:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This vection need notbecomplemd from permit Is foram hundred dollars nlffl)
or mss.)
1 cenifY that in the performance of the work for which this permit is Wood.I shall was
employ any person in try man! o gjm the e workers'CompensationLaws of California.Data
F
Applicant L;'d r
NOTICETO APPLpA :IL arm,auddl(j'thls Cmainceaw of Exemption,you should
Woman subject as the Worker's Compensation provisions of the Inter Coag you muse
0z forthwith comply with such provision or this permit serail W deemed revoked.
z,y. CONSTRUCTION LENDING AGENCY
IWmby m@rm that arm is.coutructinn mndingagacy liar Ne performance of
ai v7 the work for which this permit Is issued(Sec.3097,Civ.C.)
0.Q Lender'&Nurse
z Lender's Address
U0 I certify that 1 hale mad this application and sum that the&hose intervention m
D.r', contact.1 agrm,to comply with all city and county ordinances and ram laws mlming m
C Wilding construction,and hereby authorise repassntsaws of that city in enter upon Me
W abovwmentioned property for inspection purposes
(We)agree in an.indemnify and keep harmless the City of Cupertino against
wr
in liabilities,judgment,con,and expenses which may in my way acme against hod City
In
V M APPLLIICCANT UNDEequence or the RSTANDS AwuatTND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
sign ler m an ler
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(mum Wilding occupant mom or hanam hanaraous masadal
as darned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
caue.smtiem 2ss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yon No
Will the applicant o fuwm Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haurdnu air comenammu;u defined by the Bay Area Air Quality Management all new materials for inspection.
W,
ict?
❑Yee Nu
Ihammaldbehu s emriammquimmcnuunder ChapterG95oftheC&lifor-
ni&Hulth&Safcty Cmm,Sectim253D5.25533 and 25534.1 understand thuiftic Wilding
dm not currently haw a larval,that IT is my responsibility m notify the accupent or the
ratiolmmcn wIt hmumbcana;erwi ceohCerufcemofOccup —Signal All
Date
Dw rur sum d dg 4f oge¢ Dan' All roof coverings to be Class "B"Of better
Community Development
10300 Torre Avenue
� Cupertino CA 95014
Telephone(408)777-3228
OCIF '
Fax(408)777-3333
�UPEkTINO '
Building De artment
JOB ADDRESS: PERMIT# Z 0)3)
77 / t
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
t Glass / Glazing `
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing Re��� ^OJ gD
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/Contractor Signature Date
CITY OF CUPERTINO 0`�°2���
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # �757 0 3S Date:
Building Address:
1477/ 2C/i61E✓ st- 4vie,
Owner's Name: Phone#:
/nwleit Vo - 5(0 q — 4 6
Contractor: License #:
D&X Avxa- )U i S Sol q 3
Contact: Cupertino Business License #:
John NJanSo �
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: n 'II �
to C✓ i g h t*�I
Residential Ili Commercial
Cost of Project:
,2000• DO �
•
Qty. if
Applicable 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
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