03100210 ' CITY OF CUPERTINO x"« -^ 777777
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ' -
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Bu1LDlNc noDRrss: CLEARWATER PLUMBING PERMITNO(03100210
8145 PRESIDIO DR
OWNER'S NAME: 10429 NORWICH AVE PERMITL95UEDATE
KEVIN CROWLEY 10/29/2003
NE: 4 0 8 4 4—7 5 8 6 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BU PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
jos LICENSED ONTRd under
DECLARATION Job Description
l U I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
with Section 71)(0q of Division]of the Business and Professions Code,and my license is
SR
InmRforceandeffect. D REPIPE & REPLACE WATER MAIN
License ClasLic.g
I
Dale, Contractor
'p�p ARCHnECr$DECLARATION
understandum /
l C I understand my plans shell M used publichlicucmoonls
aed
U (D
_oI Liccnud Pmfcssionel
OWNER-BUILDER affirm DECLARATION P13
<f 1 hereby arm that 1 am exempt from Nee Contractors Liccnsc Low Iter the
o O following reason.(Section 7031.5,Business and Professions Code:Any city Or county
5 m which re uires a permit m Cnnsmuct,four,improve,demnreh,Of repair any Structure $5000
-ZY prior Bs its issuance,also mouiva the applicant for such permit tottfile a signed statement
•s< that he is licensed pursuanoTheprovisionsoftheCommcmr'sLicenuLaw(Chapter 9 Sq. Ft. Floor Area Valuation
ZFm (commencing with Section 7006)ofDivision]nfthe Business and Professions Codc)nr 35611085 . 00
CRE that he h exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by anyapplio1 for apermit subjects the aPpli..L to a civil penalty of APN Number Occu ane T e
pot m.,.than livehundred do])..u500). P Y YP
❑
1,se;owner of the property,or my employees with wages as their sola compensation,
will do the work,and the structure is not inlended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's Us,.Law does not apply to an owner of Required Inspections
pmpeny who builds or improves thmon,and who doessuch work himselfor through his
own employees,provided that such improvements are not intended proffered formic.If,
however,the building or improvement is sold within one year of completion,We owner.
builder will have the burden of proving mer he did not build or improve for purpose of
mlcJ.
❑I,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7014.Business and Professions Corlino Contractor's Li.
come law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projcets wish o contnmor(s)licensed pursuant to the Contractor's
Li enu law. ,
I sat exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of Ne fallowing declarations:
1 have and will maintain a Ceni Been,ofComcnt to ulf-insum for Workeh Compete
s ili.m.m provided for by Section 37M of the labor Code.for she pclrmmonce of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Inatrsom,as required by Section
3760 of Ne labor Code,for Ne performsucc of the work for which Nis permit is issued.
My Worker's Compensation Insmnen carrier and Policy number art:
Cartier: Policy N..: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
olsix.1ion need nm hecampleleJ if the permit is fmorc hundred dNlan($100)
or less.)
I cervi ry that in the performance of the work for whish this Permit is WOOL I shall not
employany ni nymanne o become mbjav0 the Workers'Compensation
Laws of Ca.] !O�CJa7
Applp�
NOTIpp TO APPLICANT:If.after making this Certificate of Exemption,you Should
become I bject to the Worker's Compensation provisions of Ne labor Code.you must
,'Z forthwith comply with such provision or Nis Permit shall be deemed revoked.
r O CONSTRUCTION LENDING AGENCY
I hereby-Mon Not thew is a consumed..lending agency ter the Performance of
x the work for which this permit is issued(Sec.3041,Civ,C.)
QLender's Name
= Z lender's Address
Q 1 sohry that 1 have read this appliemion and stale that she show information is
A correct.I agree to comply with all city and county ordinances and stare laws mining to
�U builw-mennswaiogand herebyaCLiOn Papuumetivrs of this city to enter upon that
„ W shove-mejudg d pmpeny forand Islamics
Poromas.
ti LL (We)ague m saw,indemnify and keep harmless the City of Cupcnino against
y
Liabilities, of
costsand expcnusmit. may in any way accmc against said City
..7 A consequence of UNDERSTANDS
Sthin D WILL
Issued by: D [e
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
SOU REG CATIONS.
( V
Re-roofs
Signature of ApplicanBCmnmctor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicam tar future building Occupant store or handle hamrdous material
as defined by the Corinth.Municipal Code.Ghapur 9,17,and du Health and Safety
cmle,section 75537P17
-1 Y. � JNm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building oecupapi use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
5if"ardnus air contaminants ss defined by me Bay Area Air Quality Management all new materials for inspection. .
❑Yca XNo
I have need the hamelnue materials requirements under Chapter 6.95 of We Califor.
nia Health&Safety Code.Sections 25565,75533 and 25334,1 underhand Thar irthe building
dors not currently haw a tinam,that it is my responsibility Or poly the occupant of the
nqm tswn
must xmet prior to issuance pro Certificate &cup y, Signature of Applicant Date
Owner or amhorin agate /e All roof coverings to be Class "B" or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# 3 S Co I/ O ao S Date:)
Building Address: 11
il S �f C' Si G I O � �•
Owner's Name: Phone#:
kevl .,, Cfowkp,
Contractor: Phone: License#:
C� r VILA - -D9306
Contact: hone: Cupertino Business License#:
5 �\e4, f t co 10Sro X40
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: 11
C9 pec (,Q , ,� g ( w ca) er a.\ ce ,M V,\
Residential d9 Commercial ❑
Cost of Project:
s
Qty. if
Applicable Fee ID Fee Description Fee Group
f 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 Dis osal PLUMBING
BUSLIC Business License BUILDING
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