03080022 clTv of cuPExTmo CONTRACTQR INFORMATION F
BUILDING DIVISION PERMIT
amLDINC ADDRESS: WATER QUALITY PLUMBING PERMIT N`b3080022
a L621 RANTA RETT-A PT
OWNER'S NAME: 1860 ALMADEN RD PERMITISSUEDATE
ROBERT I 3
ONE; (408) 267-9330 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI4
0 0 0 0
i00 LICENSED CONTRACTOR'S DECLARATION lob Description
C I hereby affirm that I am licensed under provisions or Chapter 9(commencing p
U with Section 7(j)(f lDivision 3 of the Business end Professions Cndc.end my license is
in full force andc GAS LINE
jai Liccnsc F � Llc.ps PINA,LE®
tFp Da¢ Tnq DI CLL AV
ee q 7W an CHITELTS DELLA r 1 _
< I understand my plans shall he used as public reroNs
coy Licensed Professional '
FEB 2 5 2004
q S OWNER-BUILDER DECLARATION
2 a f 1 hereby affirm that 1 am exempt from Ne Contractor's License Law for the
p O following reason.(Section 9()31.5,Business and Professions Code:Any city or county BUILDING
<m which requires a permit to construct,eller,improve,demolish,or repair any structure
priorto its issuance,alsomquires the applicant(orsuch Permit o File asigned statement
pp a that he islicensed p annaltothe prevtstoasofthe C.nvacmr',License Loo(Chaptcr9 Sq. Ft.Floor Area Valuation
iHC (commencing with Section 7")of Division 3ofthe Business and ProfcssionsCode)ser 35622021 . 00
�..
that he is exempt thetefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mare than five hundred dollars($500).
D 1,m owner of the progeny,or my employees with wages as their sole compensation,
will do the work.and thestnumum is nut intended or offered for sale(Sm.70,11,1,Business - SEWE [�CapOj1,S�
and Professions Code:The Comocctnfs License Law docs not apply to an owner of 202 — UNDER UMt3.LNG
property who builds or improves thereon,and who does such work himselfor through his
own employees,provided that much improvements esenot intended or offered for able.IL 301 - ROUGH PLUMBING
however,the building or improvement is sold within one year of completion.lie owner-
builder will have the bollen of proving Out he did not build or improve for puTose of 302 - TUB & OR SHOWER
able.)' 502 - FINAL PLUMBING ENERGY
[D 1,as owner of the property,am exclusively convecting with licensed commusiors to 506 - GAS TEST
construct the project(Sec.7044,Business and Rofessions Code)The Contractmh Li-
censeLawdoesnolapplyloanownerofpropcnywhoWildsorimproves thereon.and, 507 - FINAL PLUMBING
who contracts for such projecls with a contractor(&)licensed pursuant to the Contractor's
License Law.
[:11 am exempt under Sec. .B&PQC for
�this
+resumn
.. Owner Dale �
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conum to self-insum for Worked Comr o.
nation,as provided for by Section 37110 of the Labor Code,for the performance of the
.,it for which this permit is issued.
❑1 have and will maintain Worker's Compensation lunmance,as required by Section
3700 of the labor Cod.,for lie performance of the work for which this remail is issued.
My Works' Compensation Insuranceomieran0 Policy numMr art:
Carver: Polity ND.: `
CERTIFICATE OF EXEM ON FROMW RKERS'
COMPENSATION INSURANCE
(This section need not bccompleted if the permit is forone hundred dollars($IIX))
or Itss.)
1 unify Nat in the performance of the work for which this permit is issued,l shall out
employ any person in any manner so as it)become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become anneet to the Worker's Computation provisions of the labor Code,you must
=z rorlhwith comply with such prnvisiot or this permit shall be deemed revoked.
tiO CONSTRUCTION LENDING AGENCY
I hereby affirm Nal there is b consm¢tinn lending agancy for the performance of
Ys r7 the.,it for which this permil is issued(Sec.3097,CO.C.)
Qlender's Name
z Linden's Address
U U I certify Nati have rend this application and same that Ne Above informationterupon
t ie
(-' cooed.l agree t comply with all city and county ordinances and stem laws relating to
.�. V buildingconstruction,proend forebyemhonimreoses. tiwso(mit City to enter upon the
Na
above-mentioned gree to ertysave(odemnifyan keepee
(We)agree to save,indemnify end kith harmless the y se.f against idCtagainst
tiro in
equnce of thecoess and of this expenses which may in anyway eccmc against said City
Jz Aconsequence of DERSTingofthis permit. r�^�6 !`6
APPLICANT UNDERSTANDS AND WILL C PLY WITH ALL NON-POINT Issued by: Date d
S URCEREGULATIONS�
Mar (� ���(,2Re-roofs
Stgnamre ofA las actor Dam
HAZARDOUS MATERIALS1S LOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safely
ad.,Sutton 2553xa)? , All roofs shall be inspected prior to any roofing material being installed. i.
❑Ycs
` If a roof is installed without first obtaining an inspection,I agree to remove
i' Will the applicant or future building occupant use equipment or davits which
it ha tar lous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
istricG
❑Yea �yno
I have mad the hmardonsmaterials requirements under Chapter 6.95 of the Califon — -
nib Health&SareryCuM.Sections 355(15.25533 wJ 25534. unJcmmnd that irthe building
daps not cuteady haw a tenant at it t my resp.nsibility m nnal'y the occupmn of she
req memenowhichmus andante of a Certificate.(-Qc.aparmy. Signature of Icant Date
Owner or aumd" gem GlC' Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
REPIPE/ SEWERS/ MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN #
as Date:
331 -
Building Address:
Owner's Na Phone#:
Contractor: License #303 Dl
Contact: Phone#: J
Applicant C ntrae or:
Building Permit Info:
Bldg Elect Plu Mech
Job Description: /
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:a� D a
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
/ PPERMITFEE Pl-umbing Permit Issue PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pb1g Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILIDNG
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