03050044 I CITY OF CUPERTINO ' + '> �'"
BUILDING DIVISION PERMIT CQNTRACTQR INFURMA.TIOIV, -^•,
vMC ,O . ?st.
Bu1LDINGADDRESS: - ABLE SEPTIC PERMIT NOD3050044
18-11 SAN FFP.RmANjnr) AiTT-7
OWNER'S NAME: S20 REED ST. PERMITLSUEDA,]$ 2/2003
K LIU U�� 1
ONE: (408) 377-9990 SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
LICENSED CONTRACTOR'S DECLARATION
IY 1 hereby affirm that 1 are licensed under provisions of CMptar 9(Commencing lob Description
^� with Secilon dXgO fDivisianJor Nc BusinpyW Pmfecriuns Cade,and mylicenx is PINALED
Lfellfne Class
act. Lfe'Fj1 ` . 5 SEWER HOOK UP
.IR es DD'ownse Clue Con
1g-t
ARCHITECTS D R ON
a du.nd my pies Nell he used u public recordt OCT 24 2003
30 LicesdPmressional BUILDING
3tO OWNER-BUILDER DECLARATION
N
A E I hereby affirm(Second
I em exempt from the Crisscross License law for the
OO followhich re rt'SWa.permit
71DLS, r.alter, mpand on,professions Crede:Any city or COsany
ture
$� which requires a permit m.rower.alter,Impmw,demolish,or repair any swctum
FZS°
poor it)its issuance.also requires the applicant for such permit to file a signed stmment
�< Mal he k licensed pursuant to the provisions of the Cormcwb License Law(Chapter 9 Sq.Ft:Floor Area $6t(gbL®tion
pq $ (commencing with Section 7000)ofDivision J of the Business and Professions Cade)or
that he is exempt Nuefrmn and Ne buns for Ma alleged uempdm.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicmrto a civil penally of 39CPN3t03"er00 Occupancy Type
not mane than sew hundred dollen($500).
I,umvm of Ne property.or my amplvyeea with.stens they sok.mpcsadon,
will do the work and Ne structure is not intended oraffend forade(See.70e,Buri. L U b - bEWER 9
ctions
and Profession,Code:The Commem's License Law docs not apply to an owner of 202 - UNDERFL VOR PLUMBING
property who builds or improve Mamon,and who doess uch wink himself or through his
awn employee,provided that such impmwmenu an not intended ornanai forule.R. 301 — ROUGH PLUMBING
howewr.Ne building or improvement is mid within ave your of completion,the Owner.
Wilder will how Meharden ofproving Must hedid red Wild orimprowfor purpose of 507 — FINAL PLUMBING
nk).
❑1.as awsr of the pro'ny,am exclusively cosseting wish licensed conusemn to
..net Ma project(Sec.7044,Business and Professions Cade:)The Conuacmis Li-
am law does not apply to an owner or property who builds or knpruwa Maroon,and
who contracts for such pmjec%with a contractor(s)licensed pursuant to Um Contractors
License Law.
0 1 am exempt under Sec. .B&P C for this noon
tuner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of de following declantias:"
I haw and will maintain a Cenificm,of Consent to self-insure for Workers Compen-
ution,as provided for by Senkn 7700 of the labor,Code,for Ne performance of the
work for which this permit is issued
❑I haw and will maintain Workeri Compensation Insurance.u required by Section
7700 of the Labor Code,for the performantt of she work for which dos permit u issued.
M orkeh Compensation lnxnne artier Po number m:
mer. rn�rr_4 Na.:5561 7/0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This union used not be complcted if be permit Ill form=hundred dollen(SI W)
or Ices.)
1 certify Nat In The pctfa mance of Ne work for which this permit%ismed,I shall not
employ anypenon in any manner an as to become mbjecr to the Warkeri Compesadon
Laws of CaIifomla.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccniacam of Exemption,you should
become subject in Ne Workers Compensation provisions of Ne Ulear Code,you area
0 foMwith.mply wish such provisions or this Permit lnil W doomed mwked.
Z O CONSTRUCTION LENDING AGENCY
[-o I herby affirm that Nen Iseion lending agency for the performance of
gl:> the wort for which Nu permit%issucd ed(Sm.(Sec.3077.Civ.CJ
CA
lender's Name
=)z (endar,Addmn
U Q I certify that I haw read this application and seem that the show Inform W un is
I[.F corncL I agree m comply with all city and county ordinances and sum laws missing to
DU building construction,and hereby mdumme npresenudwr of this City to COW upon the
4g7 abovcmenilmod property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupcnino against �r
y liabilities,judgmenu,cos%and expense which may in my way steres against aid City
Uz in cosequencc of the totaling of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 RCE REGULATIONS. _ 12 �0 3 -
rr io Re-roofs
i noun of pplicandConuacmr Data
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the applicant or future building aceupmtstore or handle huardow material
u defined by Ne Cupenno Municipal Code,Chapter 9.12,and the Health and Safety
out,Scatnn 2ss7:(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑res p}No
Will the applicant or future building occupant six equipment or dovices which If a roof is installed without first obtaining an inspection,I agree to remove
all hmardous air contaminates at dcEned by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
❑Yea IA No -
I have mW Ne hmardous materials requimmenu under Chapter 6.95 of she Califor-
aiaHealth&Safcty Cade,S.dom 25505,25533 md25534.1 understood thatifthc building /f 5'— )Z - B
does nod canard,hew a tanant that it k my resposibility to Wal'y the accup.,of Me
mquinments which mus be met pd.,miss...ora CardOcsaraauFancy. Signature of Applicant Date
., s—i2 P3
fir or authoriactl agent Dan All roof coverings to be Class "B"or better
CITY OF CUPERTINO ca
' REPIPE/SlEWERS/MAIN SERVICE 0
ICUPEVINO PERMIT APPLICATION FORM
APN # 35 O Date 2
J
Building Address:
2-193 , n cr n�l d AV —`
Owner's Name: Phone #:
n h
Contractor: P ne: License
Jt It cOj'ic H -777- C? 990 j;�-)-7 475
Contact: Phone: Cupertino Business License #:
ZU Y;7 r`l t&82 39 S,
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 19
Job Description:
ui
Residential ® Commercial ❑
Cost of Project.
G
00 ci
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE —Bldg. Permit Fees BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i eofFixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
l � 7.