04120033CITY OF CUPERTIIYO
• ,ar7 '
� .+e:^S.»a_791
Yp-
BUILDING DIVISION PER1k,T TT_~-
COL\tgRtl1Yl�W'l
BOIWING ADDRESS: -
ABLE SEPTIC
P°IMITN%4120033
21875 SAN FERNANDO A
OWNER'S NAME:
PERMIT ISSUE DAM
CLARA MO
520 REED ST.
ONE:
SANITARY NO. CONTROL NO.
(408)377-9990
ARCHITECOE1401NEER
-
BUILDING PERMIT INFO.
.. - ... r•..
-
BO EO PLUMB
0
LICENSED CONTRACTOR-PECLARATION
Job DBSCTIpuOn "
at 1 w lice none ofChapter 9 (commencal
iNSectiU).fDividon 3.fWC Bud a rid Profusion, Code, and my Recounts
1001(11
in mu(Vf(an, -• •-..
_ -
LATERAL C/OLice
Cl(_ Ai'Z . A
Data
ARCHITF.CI'SD ON
I uMe✓r l mY Puns shall he used a , is recnms
� - '
Licanrtd Profesommi
OWNER -BUILDER DECLARATION
I bercby affirm that I em exempt from On Contractors License Lew for the
- • -
following moon. (Section 7031.5, Business and Professions Cour: Any city at county
which requires a permit to conmiuct alter. Improve, demolish, or repair my nrucwm
nn 7—
prior N its lssmnce, alm requires the applicant rarmch Permit in ale signed statement
Nat he a licensed pursuant In the prevision Of IM CommLi Law (Chapter 9
.• Sq. Ft. -Floor Area
Valuation '
(commencing with Section 70DO)of Division 3 of the Busimasmd Professions Code) or
..
that M is exempt Lwa from and the basis for.Ne alleged exampdan. Any violation of
ello 0
Occupancy Type
Section 7031.5 by any applicant far a permit wbjecu the applicant m a civil penally of
not morethm Ovebundmtl dollars (5500).
❑ I. as owner of the property or my wplay. with wages their man campewtion.
Required ections'
will do the work. and the not intended TOM. Business
r We (Sm.to
m awrcr of
And Pmfeadons Code The Commutes uses License Law tion,(o.1 Apply
q p _-
propmywbo builds.,Wis. thrcon,and whodoeaauch work hanoctor thmugh his-
awnemployw, provided Nn each improvements meant Intended arofferad(orale. a,
however, she building or improvenent is mid within am year mcompleuon. the owner-
, . -
builder will have W burden of proving that he did not build or Improve (a purpose of
I ,•
❑ 1, a owuer of the property am exclusively contracting with licensed conoacurs in
-
chnsouct the pmjea (Sec. 7044, Business and Professions Cattle:) The Conhacmra I.I.
, i' ..;i' _ ,• -
came Law don, not pply in an owner of property who builds or improv thereon, and,-
whoconwetsforeachprojectswithaconoicmr(U licensed pursuant he the Contractors
-•— •,-7 •- �- - ,
License Law.
- -
❑ I un exempt under Sae. B A P C for this mann
Owner Date
WORKERS COMPENSATION DECLARATION
1 thereby a10rm under penalty of perjury are of the fallowing declanowers:^-
nmfa Workers Cheapen -
'IMveand will mCertificate Consent tuml(dw
ssuan, u provided for by Secdan 3700 of Our Labor Code, fm the performance of the
As
work for which this Permit u ismed.
have and will maintain Workers CompensationImm�nce, u mquimd by Section
of.fthe
- - — -
labor Code,f.rNe performance of de work fm which Nu permit is issued.
rkera Compensation lnsurancec mand cy number am:
a, 15,1 fr 70wayA, yNO.:
CERTIRCATSOFE% OM WORKERS'
. ..
COMPENSATION INSURANCE
(Otts ate ian need not becomPlcted Ifft Permit is Wane hundred dollw (5100)
or loss) -
-
I unify that in the performance of are work for which this permit is Issued. I shill not
_ -
employanyParsoninmymaorcrsoutobecamesubjecttodteWarkeriCampewtion
-
Laws of California. Data
- - ----' `-
Appliunt-
NOTICE TO APPLICANM If, alter making this CeniOcae of Exemption, you should
became subject in the Worker's Compensation provisions of the lama Cade, you mw
forthwith comply with such provisions or this permitshall M denoted revoked.
CONSTRUCTION LENDING AGENCY
1 herehy affirm that Nem its eoruwcunn lending agency for the performance of
-
-
the work for which this permit Is Issued (Sec. 3097, Civ. C.)
-
Lender, Name
-
Lender's Addmat
I cenify Nm I have read thia application and team that thO show inf. r.si.. is
comet. I agree In comply with all city and county ordinances and tum laws mlmng in
building construction. and hereby authodm reprexnutiv of this ally in enter upon Ne
'
i shove -mentioned pmpeny for inspection purposes.
(We) agree to taw, indemnify and keep homeless the City of Cuprmm against
j Iimilides, judgmmus, come and expenses which may in my way acme against and City
in consequence of the Swung of Nu permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WRFI'AbJ...NON-POINT
Issued by:. Date
�aURCEREGULATIONS. ✓/
\ /l2 vg ti✓! �1 ___; �z-6-o1/
Re -roofs
Type of Roof
ig rcof ApplicanUConummr Date
(!0R"HAZARDOUS MATERIALS DISCLOSURE
Will are applicant or future building Occupant stare arhandle hmamoa material
As dcOmd by the Cupertino Municipal Coln, Chapter 9.12, and the Health and Safety
Couc, Section 25532(.)7 �
All roofs shall be inspected prior to any roofing material being installed.
❑Yat GIN 0
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by IM Bay Ama Air Quality Management
all new materials for inspection.
DW icG „f
❑Yes [KN.
I have mad the haardm s materials requirements unJerCMpmr 6.95 of the Califial
out Health B SafcryCodc, Satiate 25505,25533 and 25334. l undermsd the i(de building
does not currently have a Tenant, then it u my responsibility in ImufY the oneupent of the
cnawhiahmwxmetpriormiuuancearaCcma ofoccupermy.
Signature of Applicant Date
�� Y,n r--,oN
All roof coverings to be Class "B" or better
mer or wthorivad ageal Dam
17
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB, ESS:T i
91'?'75' SAIJ rLYY'0Ato X> CU?'v�i eke �`�1 t
ERMIT #
/
OWNER'S N LIJerQA v� o
PH 3-7'7 a`t O
GENERAL CONTRACTOR:
FX< #
I am not using any subcontractors: G�
Si afore �te
Plaaca rhark annlirahle enhrnntrartnra and cmmnlete the following informatiota:
r
ontractor Signature
12•-�—oy
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
Asl,f-- tTNA 2F 1'L�n 12fJ 1
Roofing
Septic Tank
Sheet Metal
Sheet Rock,
Tile
r
ontractor Signature
12•-�—oy
Date
CITY OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE o Cf / 2 o 3
PERMIT APPLICATION FORM
APN #
(S^
/
°�J
Date:
oc{
Building Address:
Plumbing Permit Issuance
PLUMBING
11$lS
5-a>7 'i�-rNA ADO C-ur-f-kr R no
PLUMBING
Owner's Name:
Pbl . Fixture
Phone #: (,o
C L AizA-
wA 0
�� 823-5'�1 1
Contractor: Phone:
P�C3C 17t �RC�t2ou 1.z1
License #:
(z>—I`) 4-7
Contact:
vk6tF�rJ
P
one:
4OfS�
Cupertino Business License #:
Building Permit Info:
EnergyBUILDING
Bldg ❑ Elect ❑ Plumb ❑
Business License
Job Descriptio
i
Reside 1
Co mercial ❑
/
Cost of Project:
i
Qty.if
Apt(icabl� Fee ID
Fee-. T)Pcrrintinn
Fea C;rnnn
BPERMFEE
Bldg. Permit Fees
BUILDING
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
EnergyBUILDING
BUSLIC
Business License
BUILDING
7
i
� Z31.