03060064CITY OF CUPERTINO
C
BUILDING DIVISION PERMIT
��tbNftXCTOR, 00MAT-10N
UP
a auliLDING ADDRESS:
n -� j n PT I�D4 TRrr, I p
CUPERTINO PLUMBING
1111 NOO 3 0 6 0 0 6 4
1
OWNER'S NAME:
10297 S DE ANZA BLV
"8Tn9/2003
GAR AMIR T4 ANT) mpm mAqTnNFTj
1
ONE:
(4081)253-0618
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERIviry INFO
BLDG ELECT PLUMB MECH
o
LICENSED CONTRACTOR'S DECLARATION
I hemb, ffloo that I am licensed under previsions of Chapter 9 (commencing
Job Descrips�
WMINALEO
with Section 701)(r) of Division Sof dus Busimsov, I'mr.saimucadc,and ic.o. is
✓
in lull to= a elre- cl 0S
METER TO HOUSE
License C, Lk. #
JUN 1 2 2003
ARCHrrEC rS TIO
lundersand rnyplans shall boused upts ie.card
BUILDING
Licensed Professional
OWNER.RUILDER DECLARATION
I hemby affirm that I am exempt from the Commener's License law Per the
following reason. (Section 7031.5, Resinous and Prefiessions Coutc: Any city or county
which )equires, a Permit to construct, elect, improv, demolish. or repair any structure
prior to its issuance. also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant to the prevision of the Common's Uccnsm Law (Chapter 9
Sq. Ft. Floor Area
$ 1N�40tion
(commencing with Section 7000) of Division 3 of Him Business and Professions Code) or
than he is exempt therefrom and the basis Per the alleged exemption. My violation of
Section 7031.5 by any applicant for a permit objects the applicant M a civil penalty of
3AVN3Qi1T5er00
Occupancy Type
not an.re than five hundred dollars MOO).
Ej 1.4a owner Ofthe peoparly,'Or MY employees With WAPAIM ducksomorescrtameadrut,
will do ffieworkend thestruclure is but Intended or offered forsad(Sec. 7W, Business
and Professions Code: no Communes Limemax Law does out apply M an owner of
301 ROUGH
Progeny who buildsormsproves duencon,and! whodoessuch work himselfor through his
own employ... provided that such improvements are not intended mortared for We. If.
502 FINAL PLUMBING ENERGY
however, due building or improvement is sold within one year of completion, the owner.
Wilder will have the burden of proving that Im did not Wild or improve for purpose of
506 GAS TEST
ale')'
507 FINAL PLUMBING
0 1, art owner of the property, am exclusively contracting with licensed contractors to
contract the project (Sec. 7044. Business and Porhossions Code:) The Contracher's U.
cense LAW duce; not apply to an comer of property who builds or improm thereon, and
who contracts for such projects with a conandbor(s) licensed pursuant he tied Communes
License Law.
El I son exempt under Sm. B & P C to, this ninon
[)am
WORKERS COMPENSATION DECLARATION
IOwner
I hereby affinn under penalty of perjury one of ties fallowing declarations:
I have and will Maintain . CertificateCertificateof Cmumat M self-bustme for Worker's Compan.
. n. ss provided for by Section 3700 of ft Letter Code. for Its, parfiermanum of the
work, for Which this permit is issued.
❑ I have and will maintain Workmen Crumperoadmi lommuce, as acquired by Section
3110 of the Labor Code. for the Performance of the work Per which this permit is Issued.
My
My WorkeelCroppersditz. WM.7 )(Tier MudPolicynen) rN
t 0 t Wrl
obo
C pPolicY No.:
Car
CERTIFICATE OF ON FROM WORKERS'
COMPENS ON INSURANCE
(Thus section need not he completed if doPermit Is for one hundred doilarm (S I M)
sur less.)
I certify that in tince performance of the Work for which this permit is issued, I shall not
employ any Person in any meaner an a in become subject to the Workxoi Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Onfifictle of Exemption. You shouW
become subject W the Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked,
CONSTRUCTION LENDINGAOENCY
I hereby air.. that there, '!a connection lending agency for the performance of
the work rat which this permit is issued (Sm. 3097, Ci, C.)
Lender's Nunc
Lender's Address
I ctodf, dust I have read this application and marc that the above uroarned.. I.
Comeau I affrom W comply with all city and county ordinances and sum lam totaling to
building construction, and hereby auntorce representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree In save, indemnify and keep haroplass the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accom against and City
671
in consequence of the grounifing, of this Permit.
APPLICANT UNDERSTA S N-POINT
AND WILL COMPLY WITH ALL
Issued by: Dat
E REGUI.XRONS. L
:�l _�
Re-roofs C7
-I�IA ��y 1 0
Smolckq
do. of ApplijeartuCceurnewr Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building =upanLSWM or handle Ingratudours, Marton]
's defined by the Cupertino Municipal Code. Chapter 9. IT. and the Health and Safety
dc. Section 255324)?
All roofs shall be inspected to any roofing material being installed.
P-1 ycs
prior
?(No
istrict?
If a roof is installed without first obtaining an inspection, I agree to remove
r future
Will the applicant r hours building occupant use equipment or devices which
it haeardous, air contanninams a defined by the Bay Area Air Quality Management
all new materials for inspection.
C] Yca
I he. ad the hazall.haterials requireamnus under Chapter 6.95 of the Califor.
me Health & SafctyCodc. Sections 25505,25533 and 25534.1 understated that if the Wilding
does no, comer, have the? I as my otspeoutchl'1100,1 udly the nefulmot of the
n I U bounacc 0 1 C
pri I Pat: In cy,
"a"I"Au
Signature of Applicant Date
I >
I All roof coverings to be Class "B" or better
O�
or authomixed agent Date
52-
CITY'OF
CUPEkTINO
CITY OF CUPERTINO
REPIPE/SEWF,RS/MAIN SERVICE
PERMIT APPLICATION FORM
o3 U (c--5 6
APN #
Bldg. Permit Fees
/^
Date:
Building A dress:
V
Plumbing Permit Issuance
Owner's Nau,�g,�
� �
�
Re i e of Fixtures
.
Phone #:
Co tractor:/.I�.�
u'
Contact:.EZ
OW,UBuilding
AAA) �
Phone
((rUk'
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,—
25-3 -06 %S
_5 3 J OL 7�
License #:
�yqgos
Cupertino Business License #:
Permit Info:
Bldg [I
Elect ❑
BPSEWAGE
Plumb
Job Description:
/YI
T
o tws
BUILDING
Residential
-Com
ercial ❑
CostofP ject
L]
Qty. if
Applicable Fee ID
Fee neacrintinn
Fee Crnim
BPERMFEE
Bldg. Permit Fees
BUILDING
PPERMrfFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPFIXTURE
Pb] . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Dis osal
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING