04080064,CITYOFCUPERTINO+^'" BUILDING DIVISION DIVISION PERMIT
.CONT ACTgR IN ,ORM��TION *'
/
BUILDING ADDRESS:
r,27 PC)PPV WY
CUPERTINO PLUMBING
PERMIT NO.
04070064
OwNER'S NAME:
PERMIT MUS DATE
ONE:
SANITARY0. OL NO.
ARCHITEMENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hcrtby offlrm Net I m licensed under unwitlons of ample, 9 (commencing
Job Description
p
wide Seetim7")ofDWision 3 of the Business and Professions Code. and my license is
�l\Vgl ❑
Licnow nnand erreeL L`�Cy 2t(/-1'OS—
Y
REPIPE/REPLACE WATER HEATER L� �®
Licerue am L'c.
Dam 7 f1l, Q'I Contractor
ARCHITECTS DECLAR ION
AUG 9 2004
1 understand my plans shall he used as public records
q�.
fk sal
Licensed Professional
DECLARATION
Oat
LY f6 1Y (V=1
boy
from for one
that 11. acmpn from the Cants
I am exempt
1 hran
s, Coa e: Anse city o
following moon. (Sudan 703 oli Codc: Any tiny m county
. (Su B. alter. and Proimprove,
de structure
• pmrmit n cnntncl, alter. improve, demolish, or repair
which nstr
ed
poor mireissuance,mmrequires IN effluent for such permitmfile s Law summem
its issuance.
(comm islicensedwit pursuant to provision of theeBusinssa LiansessW(Chapmr9
Sq. Ft. Floor Area
Valuat on
(commencing with Section of Division 3 of one Business and lentongh) or
on. Any vi
one, he u exempt oncmfrom and dm basis far de alleged exemption. Any violent on of
e and
3 640t3K( VO 0
Occupancy e
p y�'p
Schon 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not mare than It hundred dana,($500),
❑ I, u owner order property, or my employees with wages a their role compensation,
Required Inspections
willdo the work end Nesuuclure is not intended aro@red for sale (See. 70/6, Business
and Professions Code: The Conmcmrs Lures Law was not apply m an owner of
property, who builds or im Proves thereon. and who does ouch work himself or through his
awn employees, Provided Nat such improvements m not Intended oroRered forsalc If.
however, the building ar improvement is mid within one year of amplcuom. one owar-
builder will have the burden of proving that he did not build or improve for popoac of
uta).
1, as owner of the property, am exclusively contracting with licensed contractors no
contract the project (Sec. 70". Business and Professions Code:) The ConOacmr's Li
cease Law docs not apply b an owner of property who bulnds or improm lhemmo, and
who contracts for such projects with acomnesorn) licensed pursuant to the Coommors
License Law,
"
❑ 1 m exempt under Sec. . B k P C for this meson
Owner Dem
WORKER'S COMPENSATION DECLARATION
I hereby shim under penalty of perjury one of one following deelmdome
I haw and will maintain a Certificate atonement to relf.iaure for Wmlmos Compen-
,
anon. in provided fm by Section 3700 of the Labor Code, for the performance of the
work fats which thio Permit is intend.
Vhaw and will maintain Worker'a Campeltaton Insurance, as luquimd by Section
3700of thmtabor Code,forthc or iciemaflheworkfor which Nis permin isissad.
My Workc(pylmpe dons ,ata rriu and Policy number m:
Cartier. 17e Policy No.: U O U
CERTIFICA OFEXEMPTIONFROMWORKERS'
COMPENSATION INSURANCE
071b senlom need not he completed if one Permit Isfaroom hundred dollen ($I00)
or loss.)
1 certify Net in the pufmmanee of the work far which this permit is issued, I shall not
.,
employ any person in any maacrm is he become subject to the Workers Conference
Lower California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate or Exemption, you should
become subject in the Worker's Compeamion provisions of the Labor Code, you muss
forthwith comply with such provision or this permit Nall he deemed rooked.
CONSTRVCTIONLENDINGAGENCY
1 hereby ofrrm that there its construction lending agency for the Performance of
the work for which this Permit Is.sated (Sec. 3097, Civ. C.)
Lenders Name
lender's Address
1 canify that 1 have was onia application and state that one nerve information is
contacts. I agRe to comply all all and CWhly O names and slam lewd mianing m
building convection, rateof p ta6ws.f this city mcnlcr upon dee
above-mcmioeed pro r for irGpbnm sive
(We) rte ,6 ve.' �carni fy dice harmless do City of Cupertino againr
1��4
liabilities, ,cos anda. a whmay in any wayncne againan said City
income ne the ting of n; 'i
,PPL U STAND L OM LY WITH ALL NON -POINT
Issued by: Date
SOU EG
Re -roofs
Type of Roof
rgn f PI HAZAROOD ATERIALS DISCLOSURE Damm
Will dee applicant or future bull mg occupan, sort or handle haardous material
defined by one Cupertino Mu cipal Code, Chapter 9.13, and one fiction end Safely
calc,seedam 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yrs u
Will the or tiding devices
If a roof is installed without first obtaining an inspection, I agree to remove
applicant um occupant use, equipment or which
mit hmondnus air coruminan mCd the Bay Am. Air Queenly Management
all new materials for inspection.
Dislrin?
❑ Ya /I
us
ih madth m malt' Is nuumler Chapmr6.95oflhe Califon.
nia Hcal d: socia 6.25 5 3 d2553 imutcmandthuifNchuilding
down c as th a. p mi amity de uccupam of the
roqui a x' min o "n mor Occup y.
Signature of Applicant Date
� r I D
All roof coverings to be Class "B" or better
0 rind.sent
o-
tonee
CITY OF
�UPEkTINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
artment
JOB ADDRESS: PERMIT #G �07M( -
15P Q
OWNER'S NAME: PHONE # V68 • 'D5. B3'7a
GENERAL CONTRACTOR:,I,',,L-Ae,,,-Iiao'Pumbir4),-iI FAX # y� • Z53 nL72
I am not using any subcontractors:
Please check anolicable
rmmnlafa hha fnllnz�rinrr in Fnr•m�ti.....
7,Iq.0
Date
Owner/ Contractor Signature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
I
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature Date
•
0
a
CITY OF
CUPEkTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
� �6
APN# 5(1/1
l
Plumbing Permit Issuance
PLUMBING
PREPIPE
Building Address: 5` ) I
/ J
PLUMBING j
PERrMFEE
Owner's Name:
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BUILDING
BPFIXTURE
PW 7ZS-6 7
J7�
Contractor: Pone:
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2s vc� �
Main Water Service
Lice se #:
�Z��c;�"
Cyncact: P one:
�U�Cupertino
2 '3
PLUMBING
Business License #:
Building Permit Info:
Bldg ❑ Elect ❑
Plumb
B LIC
Job Description:
(�
BUILDING
(j—Y
Residential Commercial ❑
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Cost of Project: L�C1
Qty. if
applicable Fee ID
Fee Description
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
PREPIPE
Re i e of Fixtures
PLUMBING j
PERrMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pblg. Fixture
PLUMBING
BPWS VCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
B LIC
IL Business License
BUILDING
I
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