04010145 CITY OF CUPER'PINO ' "i' • ' ` "' '•? - - -
BUILDING DIVISIONPERMIT CONTRACTOR INFORMAUW ,;
BUILDING ADDRESS: MIKE COUNCIL PLUMBING INC PERMITND04010145
OWNER'S NAME: - PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITELTMNGINEER: BUILDING PERMIT INFO
BLDGELELT PLUMB MECH
l� 0 0 0
Z
LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am limnsed under provisions of Chapter 9(commencing p
wifh Sectionl"I of Division 3 or 6.Easinc Pmfcesiuns Calc,end my liccnu is
eor°n inccnlfnme na rze ,32 .@y9ifo�-gz(� 1 REPLACE SEWER LINE
Li se Cl LIc.1r
FINALED
,3Q ARCHITECTS D RATION
y B'� I understand in,plans shall he used.,public mcmds
oLicen J Proftaainnal FEB 0 5 2004
�to OWNER-BUILDER DECLARATION
<2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
O yO following mason.(Section 7131.5,Business and Professions Code:Any city or county BUILDING
K m 9 which requires a pemlit In construct,alter,improve,demolish,or repair any structure -
yai poor its issuance,also requires the applicant for such permit to file a signed statement
££ 6 that he is licensed pursuant It)the powisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
z 3 (commencing with Section 7")of Division J of the Business and hot
ColeJur
thhe is exempt dEmfrom and the basis for the alleged exemption.Any=of wog r.Aas.aA
Section7RILS by any applicant for apermit subjects the applicant to a civil penalty of 3'fD Ytv6 VYllWQrOO Occupancy Type
not more men fin hundred dollars(3500). P Y YP
1,ax owner of the property,or my employees with wages as their ole eompenutud,
will do the work,and the."came is..I of ffamd for sale(Sec.1044,Business
and Professions Code:The Convanm's Lice.e Law does not apply to an owner of Required Inspections
property who builds or improves Nemon,and who does such work himself or through his
own employeus,provided that such Improvements one not Intended or offered for sale.IL
however,due building or improvement is sold within one year of completion,the owner- -
builder will have the burden of proving that he did not build or improve for purpose of
.1.J.
❑1,as owner of the property,am exclusively convecting with licensed comments;to
contract the project(Sec.70",Business and Professions Code:)The Commentsi Lt. _
came Law does not apply to an awnar of property who Wilds or improves Nemon,and
who contracts for such projects with a contractor(&)licensed pursuant On the Contractoii
License Law.
❑l am exempt under Sea BA PC for this...a
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aMm under penalty of perjury,one of the following declarations:
I have and will maintain a Certificate of Collum foself-insure for Worker9Campem
gotten,as provided for by Section 3100 of the Labra Code,for the performance of the -
work for which this permit is issued.
0'1 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of Ne labor Code.for the performance of the work for which this permit is issued.
My Workeh Compensation Insurance carrier and Policy numkr am: ut.[Lp\
Ca ''PPMMttpyJJ�G zo 14 6
CERTIFICATE OF EXEMOM WORKERS'U 11/Z 4%)
COMPENSATIONTTNSURANCE 1 '
(This tial...it not he completed it the permit Is Toro.hundred dollars($100)
or to..)
I our ify that in the performance of the work for which this permit is handed.I shall not
employ any person in any manner u as in become subject o the Workms'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Centricam of Exemption,you should
become subject in the Worker's Compe.a0on previsions of the Labor Code,you mot
.,O forthwith comply with such provisions m this permit shall be deemed revoked.
'� _
..,vy - CONSTRUCTION LENDING AGENCY
[—� I hereby affirm that there is a construction lending agency lot the performance of
ai > tht work fur which this permit is iuued(Sec.3091,Civ.C.)
W Q Lender's Name
z Lender's Address
U C) I certify that I hate read this application and sum that the shove information is
t!. F correct,I agree to comply with all city and county mainences and suite laws Elating to
Q U building convection,and hereby authmtre representatives of this city to enter upon the
4[1
'Now-mentioned nupcst for penes purposewhich ms.
G (We)eF..to save,indemnify and keep hamtless the City of Cupertino against
sty In
liabilities,judgments.of the
gratsin of
which may in any way acetic ageing saitl City
U",� Aconsequence NDERmnVDS this permit.
F.t APPLICANT UNDERST DS AND WILL COMPLY WITH AL1:NON-POINT Issued by: Date
SOUR EGULAT
7.
Re-roofs
ago rc (Applies Ont o De -
zA ATERIALS DISCLOSURE Type of Roof
dl the appli ant or future building occupant nom or handle hatuhmous material
as tied 1 me Cu nine Municipal Code.Chapter 9.12.end the Hualth end Safcfy
c,Section 255J2(a)? p p y - g being installed.
C3, ,�N„ All roofs shall be inspected riot to an roofing material bean
Win the app cam or future building=upon(a equipment or dcv;eca which If a roof is installed without first obtaining an inspection,I agree to remove
it hannious air contaminants as defined by the Bay Amu Air Quality Management all new materials for inspection.
tract?
CYcs
I have mad the haran4a materials requirements under Chapter 6.95 of the Califon
nig Heald&SafcfyCode,Stefan.25505,255JJ and2554.1 uT` load thm if the building
Jots not currently haw a tenant.that it is my Espmd; m notify the occupant of the "
aqui owhich I at nissuance of.Cent, f«a y. Signature of Applicant Date
w rmamhori'rcJ esti p,„e All roof coverings to be Class"B” or better
CITY OF CUPERTINO I
REPIPE/SEWERS/MAIN SERVICE J ��
OF
CUPEkTINO PERMIT APPLICATION FORM
APN# 1 � 0 Date:
8 ( ft d `l
Building Addres .
PYA c,,, arRso
Owner's Nameh., Phone#:
�'�
Contract Phone:
ContacPhone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job DescriptionA
//''�� l I rra ti- a
Residential ❑ Commercial
Cost of Project:
. 'f
ble Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bld . Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
3 � 7