04080156 CITY OF CUPERTINO -
suaomc mvlslon PERMIT CORA 'OR INFUt211�IA.'TQL ,
• Bu1LDINGADDRESS: NATIONAL ROOTER PERMIT No.04080156
• OWNER'S NAME: PERMIT ISSUE DATE
VIVEK A
ONE:
SANITARY ONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION lobDescri tion
Ui 1 hereby affirm Nat 1 am Iimnscd under provisions of Chapter 9(commencing P
^i wOh ScrotaB7pg7)af Division 3of the Business ofusinns Code,udmyliconx is I- ■ - � ®
mrml rbtgpim mrc_ Lig 76Q.3�v REPLACE WATER LI �ml�alyq''ja,G,p` H USE)
N Z Licenu Clan¢
q Dae Contractor
n W ARCHITECTS DECLARAWN
<3 I understand my plans she]be used as public mcorda AUG /
D6u 2004
3O Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby alnnn that I am exempt from the Contractor's License Law for the
aO following manna.(Section 7(13 1.5,Business and Professions Code:Any city or county
K a� which requires a permit to convect,alter.improve,demolish.Or repair any atrumum
e—to prior m its issuance.also requires the applicant forsuch permit to film a aigneJ statement
tx�x< thatMislicensedpursuanlmtheprovisionsoftheContractor'sLimenxlaw(Chapter9 Sq.F[.Floor Area Valuation
c�SF$ (commencing with Section 7000)of Division 3 of the Business and Professions Caic)or
that he is exempt Netefrom and the basis for de alleged exemption.Any victual on of
Section 7031.5 by say applicant for a permit subjects the applicant m a civil penalty of 3 ] Isle eir0 O Occupancy Type
net mom Nan Eve hundred dollars($500).
❑I.uownuof Nepmp ay,armyemployceawiNwaguma irmlecompensadon,
will do the work,and Nestrueture is notintended aroQered loosen(Sec.7044,Bananas
and Profetalons Code:The Canuecmr's License Law deo not apply on an owner of Required Inspections
propertywho bulldsorimproves Nement.and whodoassuch workhimself orthmugh his
Own employee,provided thmsuch Improvements am not intended oraRered forum.If.
however,the building or improvement is sold within one year of completion.Ne owner.
builder will have tho burden of proving that he did not build or improve for purpme of
nam.).
❑1,as Owner of the property,am=elusively contracting with licensed convectors to
convect the pmject(Sec.7044,Business and Pmfusiom Code)Tim Contractors U.
cove law does not apply to an owner Of property who builds or improves demon,and
who convects for such pmjeem with a contractor($)licensed pursuant an the Contractor's
License law.
❑1 am exempt under Sec. .B&P C for Nis moan
Owner - Date
WORKER'S COMPENSATION DECLARATION
1 hereby of ore under penalty of pedury one oftie following declustiom:
1 be-and will mounted aCenifi=m of Comenl m self-insum for Worker's Camped
103ZO
und,u pmvided for by Section 3700 of the Labor Conde,for Ne performance of the
k for which this Permit is issued.
CD I have and will maintain Worker's Compensation Insurance,u required by Section
of NC labor Code,for the performance of the work for which Nis permit is lamed.
y WorkoYs Compensation Insmanm certiu and Policy number am:
me' e OWEN1 T d.: WO K iS'I D(�.Q ,3
`/ CE�RTIFI ATE OF E%E FROM WORKERS'
COMPENSATI INSURANCE
(Otis section need not he completed if the permit is for one hundred dollars(S 100)
or loss.)
I certify Not in the performance Of the work for which this permit is issued.l shall not
employ any person in any mannerx as to become subject to the Workers'Compenutian
Laws of California Date
Applicant
NOTICE TO APPLICANT:If,after making this CeniEnm of Eacmpfion.you should
become subject in the Workers Compensation provision,of the labor Code,you must
.,0 foMwith comply with such provisions or this permit shall be deemed revoked.
.Zi CONSTRUCTION LENDING AGENCY
(~14 I hereby air,.Nat Vert is a comtrudion lending agency for Ne performance of
fYr ti the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Name
.7 z Lender's Address
V Q 1 cmAfy that 1 have road thin application and area that Ne shove information la
IT,
F cannot-l agree to comply with all city and county ordinances and sate laws ranting m
Q[) building convection,and hereby autharim mprexnmu tivof this city to enter upon the
W above-mentioned property for Inspection Pegmxa
6, (We)agree to five,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments,mets and expenaes which may in any way acme against mid City
O2: in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE IONS. \
0--" A? Re-roofs
Sigrusuple T Applm— andC.rfs cmr Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building occupant earn or handle huaNaus material
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health fid Safety
COJe.Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑YesO
Will the applicant or fumm building occupant use equipmen or dcvim$which If a roof is installed without first obtaining an inspection,I agree to remove
7Dirtflcr?
t harmdnus air contaminants u derided by the Bay Area Air Quality Management all new materials for inspection.
❑Yce eI have mad Nc hmaNuus maeriala myuiremcnts under Chepmr6.95 of the CalifnrHcalth&Safct� ode,Sections 25505,75 and 25334.1 understand Nat if the building
a not current ave a mnam Net it k my m pomibility w dory the occupant of the
ui c 'c uu th me 'orwism ce or a cc,dficam Of occupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
ner o uthorixa0 ag al Dam
Community Development
-- 10300 Tose Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADD / J PfIT
Y
OWNER'SN T a PHO _2tF
GENERAL CONTRACTOR: F
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 �L
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er Co tractor Signature Date
CITY OF CUPERTINO o c,
REPIPE/SEWERS/MAIN SERVICE
• CUPEkTINO PERMIT APPLICATION FORM
APN# / Date:
Building Address: //
7 6/-Ta
Owner's Name: Phone #:
e /aUa / -7y7.2
Contractor: // Phone: �y��Sg7 License#: 76 ���0
et77 tJ o
Contact:. Phone: Cupertino Business License#:
erg ` OZ5'/-D887
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Pwlacea2�=rxve c7-i Lcovfe
Residential Commercial ❑
Cost of Project:
A?'j3yjricab 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