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05080230 +CITY OF CUPF.RTINO 'a � ? 'BUILDING DIVISION PERMIT ACONTIUC"'TOR INF�OtiMA' ION . BUILDING ADDRESS: _ DRAIN WORKS PERMIT NO.05080230 0900 RTnrF, VTRW (4T OWNER'S NAME: PERMIT ISSUE DAM HEWLETT PACK 19871 NE: SANITARY NO. CONTROL NO. (408) 927-9999 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGD t� PLUMB MECH l� LOp LICENSED CONTRACTOR'S DECLARATION JbDescrip tion I hAffirm that 1 am ns licensed under provisioof Chapter 9(mmmcheciJob with Section 7000)oMbefison 3 of the Boaineaand Professions Code,Andlicensee in fall Co.And effay a�7�� re REPLACE SEWER LINE (100 ' ) j g? License Claes f---'3� Lk.Y G Ztt-- Dale Camaracbr 9 ARCHITECTS DECLARATION i oheaersund my plans'hall M wed As public meords olL Wp Licensed Pmfenioml .73 OWNER-BUILDER DECLARATION g g 1 hereby a1Tnm that I Am exempt from the Conuacmr's Licenm Law for the E O O following mason.(Section 7031.5,Business and Profcesiuns Code:Any city or county Z f?'<$� which Acquires a permit w construct,alter,improve,demolah.or repair any structure prior to in issuance.aim requires the applicant for such Permit to file a signed alatemet that M is licensed pursuant o the provision of the Cormctres Licewc Law(Chapter 9 Sq.Ft.Floor Area Valuation $ (commendngwith Section 7")aDiwOon3oftheBusiness And Confucians Code)err $4000 than he a exempt therefrom and Ne basis fa the allegam Assumption•Any violation of Sedon 7031.5 by any aPPlianl fa A permit objects the APpliahe,An a CIAI penalty of APN Number Occupancy not mac Nan fin hundmd dollars(5500). p y�� ❑I,nownerafthe property,army employees with wagesuthelr sole compenwtlon, yyv will do the Fit. a,and Ne momma is not intended offered for nic(Sec.7044,Bwimn fA� aired Inspections and Profeulans Cade:The ComecNes Limmes Law docs not apply a an owner of q p Property,who M(Idsar(mprow thereon,and he dms'mh work himself er through bis a"N),f Own anUm.tebuilding uiProv(or Met impmchimpsmid wean trot ear ofaaaaered for sale.lL holderUNe Wild he bunen of pmmnahat didAthin rcyuc of meow et.for the another. builder wiB Nw Bre burden of proving that he did owl build or Impraw for purpose of u Ty este.). AUG ❑I,u ower of the property,,Business s and cmbacting with:)Thea anhammrs m 3° 2 05 cause La Ne esokct(Sec.o an wnerofand property who Cade)The Cmue on. red U. ons'Law doe not apply je m owner of propeny.wbo Wilds rs Improves Neuron,shed, wbo conoacu for such projects with a antreror(s)Iknv¢d pursuant to the ConvaereM1 License Law. alk ❑i am exempt under See. .B d P C fm the moon Owner Data G/Il WORKER'S COMPENSATION DECLARATION 1 Mreby affirm under Penalty of perjury one of the following decla stions: 1 haw and will maintain a CaNgateof Consent msalf-insure for WadeesCompen- 137� on,A,provided for by Section 3700 of the Lahr Code.fee the performance of dec rk for which this Permit is issueN 1 here and will maintain Workee'Compensation Inmrano,As sequin l by Section 0 of the Lehr Cade,for Ne Pcrfomuce of the work far which thin Cents,issued. Worker's Compensation`Insurance carrier and Polley numbe �rrtier. .ST ldP ley No.:ZZ ��/ !( CERT FICATE OF EX PITON FROM WORKERS' COMPENSATION INSURANCE (The s min need mol W conplAted If Ihe permit is femme hundred doBan(SIM) Or less.) 1 certify diol in Ne performance of the work for which this permit 1'Issued,I shall not employ any Come In any ma rearm As to become subject to the,Worker'Compensedon . Laws of Ca ifomla.Dean Applicant NOTICE TO APPLICANT:If,after making Ne CAARate of EaetPlion,you should become subject an the Worker's Compensation pmveiom of the Later Cade,you muss ,J O fonhwith comply with such Provisions or this Permit tlell be domed ranked. CONSTRUCTION LENDING AGENCY (-n4 Ihcmbyaflurt that Nem is a construction lending agency for the,parurnance of ai 7 the work for which this permit is issued(Sec.ANT.Civ.C.) Q (snakes Name Q z landau Maw U Q i cc lfy that 1 haw mad No Appllation and state than dmc above information IF corner,I agree in comply with all city and county on in almS and sok law mining An bulldin{eommuction.and hereby authodm mpre¢nu rns of this city to enter upon Use Ly above-men fond property for inspection pugmoses Ly, (We)agree m taw,indemnify and keep harmess the City of Cupertino against N liabilities,judgments,costs and expense,which may in my my accrue sgaW,said City t.>7 ADPL A nccUNDe A NoWILLWILL COMPLY WITH ALL NON-POINT Issued by: Date r7 SOURCER LA 0 S. Ju Re-roofs Signetum of mmVComme or Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII pplicanttar future Wilding=open(nom orhandle hazardous material u @fined b CupeNna Municipal Cade.Chapter 9.13,and the Heald and Safety Am. smdanns3'(')7 4 All roofs shall be inspected prior to any roofing material being installed. ❑� WNo • Will Nc Applicant or futons Wilding occupant Iva equlpmml a devices which If a roof is installed without first obtaining an inspection,I agree to remove It havardnes air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection. AIL? www��, ❑Yes rT No Ihawreadthelaces w maedalsmpimtenuunderChepar6.95ofmheCaliror- Hcaltha Safe,yCah,Smdau75505,25533ua175534.1unMnund Nuif Ne Wilding yhawa nit a my responsibility an malty the ocupmt of the uimescnu hon I how maofsCamillieofoccupuKy. Signature of Applicant Date 4` _G All roof coverings to be Class "B"or better Owner tar awh r cd a em Date Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 � CITY OF Fax(408) 777-3333 UPERTINO Building De artment JOB ADDRESS: PERMIT # os r' ,96230 OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # - C— I am not using any subcontractors: Signature Date Please check applicable subcontractors anff 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 p Roofing Septic Tank Sheet Metal Sheet Rock Tile- Owner/Contractor ileOwner/Contractor Signature Date ON CITY OF CUPERTINO ��a 2, 3 ° '��. REPIPE/SEWERS/MAIN SERVICE D S CUPERTINO PERMIT APPLICATION FORM APN Building Address: Owner's N e: Phone#: Contractor: Phone: q + License#: S' OPj ' ! Z� ' /� Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Job Description: zFeg 0 70r Residential 17 Commercial Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING ' BPGAS Gas Pipin System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING / BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING / BENERGY Energy BUILDING BUSLIC Business License BUILDING