03100122CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
..CONTRACTOR INFORMATI0N.
`OilADDRESS:
PERMIT NO, 03100122
OWNER'S NAME:
PERIOD ISSUE DATE
NE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� t� 0
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hcuby affirm I am derp
under provisions of Chapter 9 (commencingsj'�Z_^7
/��
Dthativision and license is
with Section ]IxII) of Division 3 of the Dusincxs and Professions
fthe Bu
2Code,
�-myy
in fun force andcften./: %�t_J fQ /
`�3
REPIPE
Date Clan
Dam ea- can.
DEC
CONTRACTOR: DISCOUNT PLUMBING /0i
ARCHITECTS DECLARATION
TS
Z
I, I understand my plans shell be used as public rtcnrds
o
License) Professional
OWNER -BUILDER DECLARATION
IVES
1 hereby affirm Thal I am exempt from the Contractor's License Law for the
following reason, radium II31.5. Business and Professions Code: Any city or county
which requires a permit to construet, step improve, demolish, or repair any Structure
prior to its -urimm, also requires the applicant for such permit to life a signed statement
that he is licensed pursuant o the provisions of the Counacmri License Law (Chapter 9
Sq. Ft. Floor Area
Valuati ll836
(commencing wish Section T]DO) of Division J of the Business and Professions Code) or
that he Is exempt thcrefmm and the basis for the alleged exemption. Any violation of
t nxi iAsii ss��,,,,
3h,Blrf 9�I)tb T -f00
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicantto•civil Pendry of
not mom than twit hundred dollars (SAID).
I, u owner of the properly. or my employees with wSea u their ole compensation,
will do the work, and the structure is not intended or offered ersde (See. 7014. Basins
Required Inspections
and Professions Code: To* Contractor's License Law docs not apply to an owner or
property who builds or improws thereon, and who dons such work himself or trough his
own employees, provided that such improvements are not intended or offered for -le. If.
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving Butt be did not Wild or improv for purpose of
sale.).
El 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the pmjcct (Sec. 7014, Business and Professions Cafe:) The Contractor's Li.
.
cense Law docs not apply to in owner of progeny who builds or improves thereon. and
who contracts for such projects with a contruutris) licensed pursuant to the, Constitutes
License Lew.
I am exempt under Sec. B & P C for this mason
Owner Data
WORKER'S COMPENSATIONDECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain It CCnlBtle of Consent to ul6insort for Worker's Compere
-tion. u provided for by Stenion J]00 of alta Labor Code. for the performance of Nc
work for which this permit is issued.
❑ 1 ham end will maintain Work ft Compensation Insurance, as uquimd by Section
311W of Nc labor Code. for Ne performance orthe work for which this permit is issued,
My Work crilC�,ompensaiion lnsum,np3(\caticrand Policy number see
Carrier. �%ItiC,'�. �li' LL][ Policy No.: 6LQ
CLRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This suction need not W completed if the permit Is for one hundred dollars (SM)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner-- Ise Meume-bjecO. the Workat' Compensation
Laws of C.hromis. Data
Applicant
NOTICE TO APPLICANT: If, after making this Ccnifuae of Exemption, you should
become subject to the Worker's Compensation previsions of to labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
-
I hereby affirm the them is a construction landing agency for the Performance of
fee work for which this permit is issued (Sec. 3097, Civ. C.)
Lendces Name
_
Lender's Addteas
I comfy that I have read this application and sue that to above information is
correct. I agree to comply with all city and county ordinances and sok laws relating to
ruc hereby authoriserposes. representatives or this city reenter upon Nc
building cotioned
prolixity forinspection es.
abovementioned1.
Saw
(We) agree m-ve, indemnify and keep harmless the Cil, of
keep against
'
against
inconacquede of the gratiing ex this riwhichmay in any way accmc against fit City
APPLIANT oftheSthispermit.
III f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
Issued by: Date o
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicaMComo ctor Dela
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle haus ims material
as defined by the CuMnino Municipal Code. Chapter 9. 12. and one Health and Safety
Can, Section zssJz(an ,q/1,�No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will Nit applicant or future building =upon[ tau equipment or devices which
omit hazardous air contaminants as dcOncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes
Ihave real tit hasrieisrequirementsunder Ch Petr6.93ofdeCaiiforria
Health& Safety Code.505,25533 d 534.1im andthallfOo Wildingdoes
111,nL
Bat curt sly a it is m s ihilityotifytie ottupant ofthemuirtmeu
hi maat-c� a¢adeadit.—
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
0offilirlmdage Dae
•
-8 1
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
o3�'5°/" �q
APN # 3 / b 33/
l
PLUMBING
Date: 1(a-05
Building Address:
PLUMBING
BPERMFEE
Bldg: Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
Owner's Name:
Main Water Service
PLUMBING
Phone #:
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
Co racton
BUSLIC
Phone:
License #:
i5
V3D -G-7 0- a `k
&36 (Fj 1 3 122
Contact:
�Z
Phone:
cSO �
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect
❑
Plumb
Job Description: \
Residential 'Pi
Commercial ❑
Cost of Project: 2
Qty. if
ADDlicable Fee iii
Fnn r)nernntinn
PPERMITFEE
Plu bing Permit Issuance
PLUMBING
O 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
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