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0511009018'2 id i fWC Lo O y0, 5$E is < CITY OF CUPERTINO t��, aC0NTRACT,OWT F�ORMATIO.N BUILDING DIVISION PERMIT ,- BU RDINGADDRESS: PLUMBERS ON CALL PE'RMITNO. 05110090 010286 N PORTAL AV OWNER'S NAME: PERMIT ISSUE DATE SAGHEER AHAMD 520 MEGLIACY LANE #12 11/17/2005 NE: SANITARY NO. CONTROL NO. (408)879-9416 ARCHITECOENGTNEER: BUILDING PERMIT INFO 'BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description P 1 hereby affirm Nal 1 me lisnsed under provisions of Chapmr 9 (commencing with Section 70fMp of Oivision 3ofthe Business stall Proresslov Code. and my license s in fc it r wOUCIe!!ssayyn''d anCis, Z - REPLACE WATER PIPING FROM Lic R METER IN Dam�[ ContractorsELL �� AL I ARCNtTELTS DECLARATION D 1 undersand my plans shall be uteri n public mcoNs Licensed Pvfessia..I OWNER -BUILDER DECLARATION NOV�9 2005 I hereby .11i. turn m I aasumpt from Ne Contractor's Uceme Law for Nm i following mason. (Section 7031.5, Business and Pmroasionr Cat: Any city or county which rtquims a pwmit to consumer. alter. Improw, demalim. or repair any structure rFzA n h Ii Nle. u prior an its issuance. also requires the applicant for such pwmit In fk a signed suamrot 1 Nat he is licensed pursuant to t m provisions of the Canummrs uLcnaa Law (Chapter 9 Sq. Ft. Floor Area U d h 8 (commencing with Sao..7000) 9 Division 3 of the Business and Profaaiov Come)or e� `/ Nat he is comnpt therefrom and the basis for the alleged eamnption My violation of Aj>jaj ja er Occupancy Type Section 7031.5 by any applicant for a permil subjects Ne applicant to a civil penally of88i not mart Nan five hundred dollars (5500). 3 16 2 9 U L O 0 L as owns ardor propary, ar my moployem wtdt wages u Nei(Sec.7 ampeva Required Inspections will dofcssimCO N ems; Out apply lf rt mvrKr of The CoarianotmawnseLaw ddrara.lapply in of YW Cade: Ca q P thersor'sn. nd wW ms h through his emy wW Wilds orimprovesthrown and wW doeMaintwork hir property who W mp offered Own N art or onerW for awn employees. p imps=14 thea, howarustich or i wit arm year the Owner. however. the Wilding or improvement u colo within aro year of Wilding improvefor use of Wader will haw Ne Iwda or proving sol n<dla net build re improv for purpose ar talo.). ❑ 1. as owner of the property. am exclusively contraming with Brsved rontrumn in covwct the Mica (Sec. 10". Businw and Professions Cale:) The Cor aamor s Li- cense Law does hot apply tom ownw of propemywha Wilds or improv thereon. and. who cordon r; for such, projects with a conuanar(s) Messed ptvsoam in the Contractors License law, ❑ I am exempt under See , B At P C far that reason DaeWORKER'S COMPENSATION DECLARATION 1 hereby aRrm under Faulty or perjury one ofda following declarations: 1 haw and will maintain aCaNfaa ofCovent to self-ituum forWorker'sCompen. on, as provided far by section 3700 tar u e Labor cads roe doe padenn ame, or Ne k for which Nis permit is issued. In" I lune mM will maiouin Wwato, Compensation Iwai . as reqired by SectionO of NC labor Cade, for Nc perfomunce of Ne wart for which NU Prmit is issttQ Worker's Compensation Laurance nmier and Policy nmber art: rtier: S��k C:,waaa -z r s- Polley No.: �JLQ0 zI Z(o CERTIFlCA OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE , (Thu section heed Out W completed if the p unit is for one hundred dollars ($10() ar Iva.) 1 certify that in the ptaf smanec of the wank for which this permit u issued. I shall not Employ any person in any mannerso as in become subject to the Workers''Compensation Law s of California. Dna AM cent NOTICE TO APPLICANT: If, afar making this CetfHcaa of Exemption, you should became subject in the Worker's Compensation provisions or de labor Cade, year mus • faMwiN comply with Fah provisions or this himut.Nall be drsmad mveked. j CONSTRUCTION T10NLENDINGAGENCY 1 hereby Nem L 30 rending agcmy ren doe pcKamnattec ar crrot pa s ed (See. ' the work for which Nice permit u issued (Sec. 7037, Civ. C.) Lenders Name Leaders Address 1 cerdfy that l haw read Nis application and sum dire the above information is ' ' conal. l agree in comply with all city and county aNiwaes and sus lows relating to Wilding construction, and hereby aoNarin reweuntathes of Nis city to enter upon Eric ' movCmcntioned properly for Impecdan pmrimms, (We) agree to rave indemnity and jump harmless the City of CaPerimm agalmt 0ab0itics,jmdgmenu, eaassand ,.perm whim may In any way.a. againamid City In conheyhenee or Ne granWtg or this permit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Signmurt of ApplirunUContrmar ale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will de appliam erfulluc Wilding,aspen mom orhandle hvamov material defined by Ne Cupenlno Municipal Code. Chapar 9.13, and cite Health and Sorely de. Section zss3z(a)? .�1 ❑Yrs NO All roofs shall be inspected prior to any roofing material being installed. an If a roof is installed without first obtaininginspection, I agree to Will Oa applicant or future building occupant use equipment or devims which P g remove mit havallov air conumivnts m defned by the Bay Area Air Quality Management all new materials for inspection. Disuin? ❑Yrs Y5o I haw mad the hvaNuv ma erialsicquie menu under Chapmr 6.95of he Califor. out Health d: Safety Calc, Sections 25505,15533 and 25334.1 understand thmif irk Wilding dael MI LYnranllY halm a atINL Nat it Y my nYpmecludity b Mdry 1M =UPNt of IIID mquimmcna which mutt be mel prior Us Wounce of a CmEinsm or Oc /O Signature of Applicant Date ` e z a,, L`' mss{ �� -r All roof coverings to be Class "B" or better g r3 ner or mNorind agent � Owner w CITY OF UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS://�� // to 2.8'G /V. /'orla l 4v -e— PERMIT # 95�� OWNER'S NAME: 6.PHONE # oy —,9 YZ 3 GENERAL CONTRA OR: 10(q,6er 6.,C FAX # I am not using any subcontractors:°'— Signature ate Please check applicable subcontractors and complete the following information: Owner/Contractor Si ature Date 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Si ature Date 0 1 R,T CUPEf�TINO CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM os ar�,a APN # 31& Z°r6�2- Plumbing Permit Issuance Date: BPREPIPE Re i eofFixtures PLUMBING lr Building Address: BUILDING ;. BPFIXTURE At /oa8�ill. a�r� BPWSVCS Owner's Name: PLUMBING BPSEWER Phone #: PLUMBING BPSEWAGE Sewage Disposal PLUMBING Cont or Business License BUILDING License #: / RoM Contact: Cu ertino Business License #: r i � � /eS Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: td ; In r7T6 Residential [ CoftirF&cial ❑ Cost of PrRject: OCP Qty. if Applicable Fee ID FPe tlrcrrintinn PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i eofFixtures 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