05020176 CITY OF CUPERTINO i
BUILDING DIVISION PERMIT ' 1ONTRA.CTORRTNP`URMAT,ION
BUILDINGADDRESS: CUPERTINO PLUMBING PERMITNO05020176
OWNER'S NAME: PERMIT LSgITB DATE
ONE: - SANITARY NO. CONTROL NO.
(408) 253-0618
I
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
/�LICFNSEDCONn4d underS DECLARATION7.e./AB1kmby..70 affirm WI 1 ssn rthesed under prProles ec[hepta 9(commencing Job De�npLtU '/ �®
Section]gD)ofDiviaion3ofthe Buainw aM Profedou Com,and mylicene i, (itismumrte and er L S'U REPIPE & WATER SERVICEg entaClus Lie azm _ Contractor MAR
e�
Hr1ECTS DECLARATIONTt ' 3 1005
y 1 unwound my plans shall he used u public rtmrds
Licensed Profcsucnial
OWNER-BUILDER DECLARATION
A Y 1 hereby aflmt that I set exempt from the Commmor
's License Law far the
O B�
®INOO
following rtasen.(Section 71313.Business and Poeftedwo Cade:My city or county
3 which mquirm a permit to construct,afmr,fmprow,demolish.Or repair my structure
r �^ prior to its issuance,also require the applicant for such permit to file a signed summcm
that he uslicensed purnunt in the immumu of the Commences Uceue Law(Chapter 9 Sq. Ft. Floor Area Valuation
(comm endngwithS don]DOB)MDivislonJnf Ne Busimasmd Rofeulnna Cale)or
.. Nat he I,exempt therefrom and 0u basis for tide alleged exemption.My violation of
Section]D51.5 by any applicant for a permit subjects the applicant to a civil penalty of e10 0 Occupancy e
not more than Rw hundred doll.(5500). P y TYP
❑I,uawneoftmvo;mty,mmyomployemwimwaguuduirmic ompenullon,
will do the work and thearrocWe 6 notimended oroRered fortah(Sec.70m,Business
and Profesuou Com:The COnsseum's Uo ma Law does ant apply to an Owner Of Required Inspections
Property who bullet or tmpmws manm,and who dues such work himself m lauougb his
own employees,provided that such improvements art not Intended moffered fmsaie.IL
however,the building or improvement is sold within ore Sear of eonpleuon.the Owner.
Wild"will haw lass burden of proving that he did pmt build or improve four purpose of
tile.).
❑1,u owner of the property,am"elusively contracting with licensed contractors to
convect the project(See 7044,Business and Professions Code:)The Contractor's I.I.
cense Law mu nut apply to an owner of property who build.or improves thereon,and
who contracts for such project,with a eonmcu(U licensed pursuant o the Contowtofs
License law.
❑lammemptunder Sec ,B&PCfmthlsmkkw
Owner Data
WORKERS COMPENSATION DECLARATION
I barely aRum motor penalty of perjury ane of the following declarations:
I haw end will mainufn•CeNOcam of Consent to elf-iuurt for WOlkwSCOmpcn-
s amn,as provided for by Section 5700 of the labor Code.for lass performance of ire
work for which this permit is blued.
0 1 haw and will maintain Worker's Compensation Insurance,as required by Section
37M of The Labor Cade,for the performance of the work for which this permit Is issued
My Worker's Com Li In nems c Tier and Policy number art:
Cartier. Policy No.: ! f-4���7]�i�
CERTIFICATE OF EK PT]ON FROM WORKERS'
COMPENSATION INSURANCE
Curls remlm need notbeconplemd beds permit ls Run.hundred unit.(5100)
or leu)
I certify that In the performance or the work for which this permit is issued,l shall no
employ any person in my manneran as to become subject to the Workers Compensation
Law,of CalafOmiu Dam
Applicant
NOTICE TO APPLICANT:If,after making this Coolness,of Exemption,you Mould
become subject in the Worker)Confrontation provisions of dto Labor Com.you most
.J O forthwith comply with such provision,or this permit shall be demmu
eed cked.
CONSTRUCTION LENDING AGENCY
[—t 1 hereby IMM last Vert is a construction lending agency for the performance or
!Yithe work for which this permit is would!(Set 3097,Ci,C.)
L Q
Lender's Nu
7 z Lender's Md.
U Q 1 coolly that 1 haw read this applicadm and sum that the above information is
W correct 1 agree to comply with all city and county ordinances and sum laws mining to
0 building construction.and hereby authorize rtpmaenu0wa of this city to enter upon the
y FT7
all..nfenLimited property for inspection purposes.
L,gyp (We)agree in taw,indemnify and keep harnfmss the City of Cupertino against
GTg Ilabilldesjudgments,cumuu ms again,dexpewhich may in my way see= mid City
U 7 In covegmnce of the panting of this permit. TH
sem• APPLICANT UNDERSTANDS AND WILL COMPLY WIALL NON-POINT Issued by: Date
SOURCE REGUTATIO
Re-roofs
signuare Of ApplDue
H M ALS DISCLOSURE Type of Roof
Will appli t or future building occupant some orhandle haurdom material
as defined by tix Cupertino Municipal Com,Chapter 9.11,and the Health and Safety
cam,S euon 25553(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
Will the applicant cr future building Occupael em equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Poll havarme air conumiume u defined by the Bay Arm Air Quality Management all new materials for inspection.
Diwicl7
❑Yea ON.
I haw mad the hamrdauamawrials requirements uuler Clupmrd.95 ofthe Caiifor-
niaHmlth&Safety COm.Smdw25 5,25555am125514.iwWcmmM iftim Wilding
does ant cunendy hew,a t u my rt Ihilily mollify the occupant of the
requirements wh wen_ m 'Ecamarampmcr. Signature of Applicant Date'
Owner n arivad a t _ DaU All roof coverings to be Class"B"or better
Community Development
10300 Tone Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: l n 7y2 PERMIT # 05�L 0/ 7 J
OWNER'S NAME/: 7 PHONE # GjcjC0 0-13 1�
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Sign 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'10 U
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ ignature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# 31 Lt
G /,. I I Date:
Building Address: r V-P
O er's Name: ! 6riatoPhone #: nn
C tractor: I G License # "_2L4 q `/l��
Contact: Cupertino Business License #:
Building Permit Info:
Bldg Elect Lam} Plumb C�
Job Description:
Residential 52-1 1 1 Commercial
Cost of Project:
•
Qty. if
Applicable 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
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