04030157 C[TY OF CUPERTINO �,� , f:
BUILDING DIVISION PERMIT . ; :x r'.,• k
i BUILDING ADDRESS: PERMIT NO.
A.T.C. SERVICE INC 04030157
PERMIT ISSUE DATE
OWNER'S NAME:
SANITARY OL NO.
ONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'SOECLARATION Job Description
1 bemby a(Ttrm Nat 1 am licensed under provisions of Chapter 9(commencing
with S.M.?OM).fDiAI.a 3 of do Business and Profusions Code.and my lecust is
5q5 in full force and ettecL
z LlcmmClam L'36 Lic.p Sz�i(,zZ REPIPE
—O Dam 4—I' —can DEC R 7' c a@✓✓rr
lq- ARCHITECTS DECLARATION sitej
$� 1 undcigunJ my phos shall M wed as public"'cords ,
7 ddd
LC Licensed P Tonal O�
OWNER-BUILDER DECLARATION
a 1 W mhy.(Sinn on 1 am,Bumps from Ne Cosies o License Law for the
i p o fallowing reason.(Section 7onstr,Business and Professions Code:Any city at county
$ which its I"......
...renis to mnsuw:L a1Ne imprr such
demolish,fie pair ed ummum
prior to its issuance,elm mquims lW applicant for mchperme toicense aw(Cha mcnl Valuate n
!'m�< that he h licamod pursuant Ma provisions
of to Certificates License Law(Chapter Sq.Ft.Floor Area
irF$ (commencing with Section 7")of Division of the Business and Profusions Cade)or
�.. that he is exempt therefrom and the basis for the.11,.d exemption.Any vialauon of
Section 7031.5 by tory applicant for a permit subjects dm applicant an a civil penalty of 3 rA,B4!N09y6er 0 0 Occupancy Type
not more than Ron hundred dollen WOOL
'-J'B'1`2 V" `J
❑I.as owner of the pmpeny,or my employees with wages in their sole compensation,
will do she work and umawclme is not intended or offend for sale(Sec.70th,Budnua Required Inspections
and Professions Cade:The Co ments's License Law dean not apply to an owner of q P
progeny who builds or i mprovu thereon,and who does such work himsel(or through his
own employees,provided oatsueh improammui am not intended mottemd forule.If.
however.Ne building m improvement is mid within ane year of completion.Ne owner-
builder will have Ne burden of proving Nat he did tet Wild or improve for purpose of
.in I
❑1.as owner of she pmpeny,am exclusively contracting wish licensed contractors to
construct the project(sec.7044.Business and Prolusions CodeO The Contractors Li.
come law does not apply to an owner of property who Wilde or improve themon,and
who contracts for such projects with a carni cmr(s)licensed pursuant to Ne Convectors
License Law.
❑I am exemptunder See .B k P C fm Nis mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 bunchy afRrm under penally of perjury one of to following declarations:
I haus and will maintain a CartiRcem of Crossed In self-inmen far Worker's Comite"'
nation,in provided for by Section 3700 of Ne Labor Cade,for the petformana of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,an ne,nord by Section
3700 of the labor Code.for Ne performance of the a mk for which this permit Is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section head oat W completed if the .It Is fore.hundred dallaa(5010)
.,las.)
1 certify that in Ne performance of to work for which this permit is issued,I shell not
employsaypersoninmyrn arm must, subject to the Workers'Compensation
Laws of California,{�m
Applicant
NOTICE TO APPLICANT:If,after making this Cedificate of Exemption,you should
become subject to Ne Worker's Compensation provisions of the Labor Code.you must
�Z foMwith comply with such provisions or Nis permit shall W dcemet revoked.
z O CONSTRUCTION LENDING AGENCY
I Wrcby aRnn Net there is a c.utuction lending agency for Ne performance of
ai 7 Ne work for which this permit is issued(Sec.3097,CO.C.)
W�Q Under's Nation,
z Under's Address
U Q 1 certify that 1 have read this application and ruk Net Ne aWve inromiatiun is
It,F conoct.I agree w comply with all city and county ordinances and suite laws raising to
CU building construction,and hereby autharimmpresenuitivcs of this city to enter upon Ne
[fa shove-mentioned Property(Or impaction purpose.
(We)agree to save.indemnify and kap harmless she City of Cupertino against
M Iiabili0u,judgments.costs and expenses which may in any way accrue against mid City
U Z in consequence of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR E REGUL�AfT�Io � Re-roofs
Signetmo of Applican✓Contrector Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Comm building mcupsel3tare erhandlc hmardous material
u defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cole,Section 25532(.)? rT(�� All roofs shall be inspected prior to any roofing material being installed.
❑Yes `fl*
Will the applicant or future building Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hourdnua air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dis ict?
❑Yes [ Vu
I have..d the hvallous materials myvimmenu under Chepmr6.95.(she Califor-
nia Hco1N h SsctyCade,Sections 25505.25573 anJ 25536.1 understandshuifiM Wilding
Jou not currently haw a Wheat.Not it u my responsibility 0 notify IW occupant of the
mquicn"tswhichmsI met pnorto issuance ONccruf¢ 3 ateofOccupancy.� Signature of Applicant Date
^IT 17- All roof coverings to be Class"B or better
ner or amhorbed agent amhorbed agent Date
' Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS DRMIT#
�s �3\ `l s�p.a �R o1-Fo3okS7
OWNER'S NAME:V Sm /'7�q PHUME # ba_q or• i o o
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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 Arc Sc-evic e
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature Date
1
J
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE v �o3 b
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
B1 3 1 f RESP pip ®J�
Owner's N 7 -1�!'N 1 e: '� Phone#:
1S
Contractor: Phone: License#:
{ATL SJ6 e /00 S2 °t6zz
Contact: — �^ , Phone: Cupertino Business License #:
I 1
Building Permit Info:
Bldg ❑ Elect ❑ Plumb I�
Job Description: q
Residential IN Commercial ❑ i
Cost of Project:
• �DOCI,� � I
Qty.
if-
Appli64bIQ Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bld . Permit Fees BUILDING
BPFDCTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE
Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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