06020046CITY OF CUPERTINO
CONTRACTORINFOIRMATION•
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO. 06020046
21841 SAN FERNANDO AVENUE
R'S NAME:
PERMIT ISSUE GATE
VALERIE WHITEHILL
02/08/2006
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SANITARY N0, CONTROL N0.
CHI'IECIYENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 Muby affirm that 1 am limned under provisions or Chapter 9 (commencing
with Section 7") of Division 3 probe Business andPofessions Code, and my license is
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is
in full rameane efrmL Co $Z79io
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REPLACE EXISTING
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Lice.Class Lie. N
Dam - - Contractor 7kfAa. /-f - ? [tet r
NEW LIFE PLUMBING. IN PA R B/L AT THE SAM
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ARCHITECTS DECLARATION
I understand ns nd my shall be used d records
TIME FEB �-
v100Q
U
plan public
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In
Liceoud Profcssirml
OWNER-BUILDER.1INoerptfir DECLARATION
RATION
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I hcrchy affirm Nn I am exempt from be License Law for 0n,
following reason. (Section )1131.5, Business and Pmfvsiuns Cock: My city or county
which requires a permit to IncSWCt, alter. ImpmM, dCmnliM, M repair any slmcWm
BUIL � '
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prior m iu issuance, alw requires tk applicant rorsuch Permino file a signed sulcmcm
thatWislicensedpu..h((.NcprovisionsofftContractor anulaw(Chap¢r9
Sq. Ft. Floor Area
Valuation
$
(commencing with Smtion 9000) of Division 3 of Be Business and Professions Cook)or
1000
.
that he u exempt Ncmfrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of
APN Number
Occupancy Type '
net moa has Bw hundred dollars (5500)x
Q 1,. owner of the pmpeny, or my employers with wage.. their sole eompenudon,
will do the work, and the structure Is not intended or offered (or sale (Sec. ]DOC, Business
Required Inspections
and PrefeWons Code: The Conwcbr'. Lienee Law does pet apply m an owner of
progeny w ho builds m im proves de mon, and who does such work himul f or through hu
own a provided that such improwmenu are nos intended fofsal
haw the buildingmplinimd
i ior,
however.not year ofimprovdfn.or Ne ower-
eingthad
_
the thuimprow
r will did
builder wire M1ave the wrdcn of proving that w aid not build or improve far purpose of
talc.).
❑ 1. as owner of the property, am exclusively contracting with licensed contractors to
commost the Mica (Sec. 7014, Business and Professions Code:) The Contrac.rs U.
mase taw docs not apply he an owner Of pmpeny'who bolds Or hormones daemon. and,
who contracts for Such projects with a contracter(s) licensed pursuant to the Consramoes
Lkenu Law.
❑ 1 am exempt under Sec. . B & P C for this mown
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pcomy of perjury one of the following declanuons:
,
I haw and will maintain aCeniOnm of Conant m ulf-insum for Winkles Compen-
sadon, as provided for by SttGon 3000 of the Labor Code, for the performance of the
work for which this permit Is 14aed.
1 have and will maintain Worked Compensation IIIsu mal, as required by Section
3100 of the Labor Code, for the perforromee of the work for which this permit is issued.
My Worker's Cempemation lnswanc/pcartie and Palley number are:
Carrier. 9"FGf?'�U-'W Policy Na.:�7�%—�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scctimmeed nolbecompkmd ifthe permit is foronc hundred dollors($100)
or mail.)
I cadfy that in the performance of the work for which this Permit is issued, I "I not
employ any person in any summer an as in become subject to the Workr2'Compensation
'
Laws of califomia. Data
Applicant
NOTICE TO APPLICANT: If, after making his Cenificam of Exemption, you should
become subject m the Worke(t Compensation provisions of the Labor Code. you most
Oforthwith
comply with such Provisions or this Permit mall w deemed paned.
h
CONSTRUCTION LENDING AGENCY
1 wmby elft. that then is. conwuclinn lending agency for the performer. of
the work for which this Permit is issued (See 3091. Civ. C.)
QLender's
Name
1<nder'SAddrees
z
Q
1 ar ify that I have read his application and sum that the above information is
FCoRCCL
I agree to comply with all city and county ondom ees and stat lam mooting on
building construction, and hereby mounie mpresenutives of this city to sit
V
crua upon
W
l move -mentioned propefm inspection purposes.
(We) agree . save, indemnify and keep harmless be City of Cupcnim against
liabilities.
y
2
Judgments, costs and expenses which may in any way acc.e against said City
in ICeof the training of Permit.
APPLICANTs
UNDERSfANDS Am
AND WILL COMPLY WITH ALL NON -POINT
Issued by: - - Q G
DateSOURCER�
L /'d(
p
Re -roofs
SepfcanComouctor Dare
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle havardous material
def.cd by the Cupertino Municipal Code. Chapter 9.11. and the Health and Safety•.
Section 25s3z(a)T
❑re, ,eNp
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future wilding oscupanr me equipment at devices which
If a roof is installed without first obtaining an inspection, I agree to remove
With lumdous air coronations as defined by Use, Bay Area Air Quality Mamgcmcnt
all new materials for inspection.
District?
❑Yes 1pt0o
I have reW the haraodous materials requirements under Chapter 6.95 of the Califor.
nia Hcalth&Safety Code, Scetions 25N)5. 25533 and 25530.1 understaW We ifohe wilding
docs not amendy have a moanh that it Is my mmumihiloy to notify thc occupant of the
rabibengnu h.9e.torierinvall cer.Cenm
iflm,ofCcpem
Signature of Applicant Date
`z' z �
All roof coverings to be Class "B" or better
Owner car amhonrn.
3a'ge'
nt Date
i
Y � F
CITY OF
PEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building De artment
JOB ADDRESS:
2189 I Sar.3 8rie-- _
PERMIT #
e z0 6 ct (,
OWNER'S NAME •: Q /� G t e
PHONE #
GENERAL CONTRACTOR: At1jadFAX
#
/ `
I am not using any subcontractors: � Z -eg - 041
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
—8-0 6
Date
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
—8-0 6
Date
firCITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
1 /11, 6 ' i
APN # 3
54 - 1 `7 — 04t -O Date: -z- & , o �o
Building Address:
2/ 14 r Sa 02ti
Owner's Name: Phone #:
X91- /-/Go -7
Contractor: , . Phone: License #:
N,pcoZ(FP ,, Z6/ --3//6O S-2/ 5196
Contact- _ Phone: Cupertino Business License #:
Pa'-F2(�C —� i ZG/- `f6a
Building Permit Info:
Bldg ❑ Elect Plumb Mech L�
Job Description:
Residential Commercial
Cost of Project:
Strapped On Platform ❑ Bonded ❑
New Location ❑ Replacement 0 -
Qty. if
Applicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
Qty. if
Applicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING