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04090273 CITY OF CUPERTINO " !' ems '� - BUILDING DIVISION PERMIT WNTRACTQR TNk'URM,T . BUILDING ADDRESS: D' S 'PLUMBING PERMIT ND04090273 '110212 RANTA M ARA AV NER'S NAME: FERMIT ISSUE DATE OW LARRY GARCIA ONE: SANITARY N0. CONTROL N0: ( 2 3 —q424 4 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u00 LICENSED CONTRACTORS said Ide DECLARATION Job Descri NAL O 0 [toiF 1 hereby afLIC Met 1 em ONTRA under Prov'fans A ION Y(commcndng wiM o 7")oGivlsion3of line Busineaaen fcsainru Cgde,end deny is ED n mu .neerrea 7/SCJ SEWER CONNECTION & C/O _ +^ �e � �qz are las Co.a Dau ^c:d Conuacmr OCT 1- 1004 . ARCH CPSDECLA � 1 undertund my plans chain be useduP06(i ads ,tt; Licensee Professional OWNER-BUILDER DECLARATION BUILDING I hereby aRfm Nm I am exemxemptptfrom the Gonaralnr's License law for fee i a 0 following mason.(Smdon 7031.3,Business and ProRtiuu Codc:Any city or county a M which require a permit to contrarian,alter,improve,demnluh,air repair any struclum fZ> priartoiuiauanpursuant intoe lM applicant Me Contractor's Benum LaeJatatoment < Nu he islittucdpunuantroduproviaiavofthcComm�ohUcensclaw(Chapmr9 Sq. Ft. Floor Area Valuation ae (commencing with Semon 7000)o(Division 3o Ne Business and Pm@sions Code)or .. Nan ha u exacttherefrom and die Ensu fix,Me alleged exemption.Any violation of Smdun 7071.5 by arty applicant for a Permit ubjncta to applicant to•civil penally of 3 2ffl220iftirdierO 0 Occupancy Type not mom wan five hundred dollars(M). ❑I,u Me work. the prnpvty.re is intended wtthwned Roor.(sok7044,BsNnn, win dothewark.and theewnureunoanteicense aw dor not apply in in Buds•• Required Inspections and ennywhiou Coen:The Cnnuacwfa License Law doe not surely if ail owner of Q P manam tubo Wiles oded that fe hoptowndwha doonotmh work himself edthrough his how a however. Me building provides Nal such impmwmants am not ear dedetc of offered(orale,if. however.we buildingerlof prove,last did one year of completion,we owner. aide.) will haw tits Wreen of provide dun he did wt Wild ar Improve for purpose of sale.). ❑1.as owner of the property.am exclusively comraning wife licensed aanaranon m construct the Project(Sec.7W1,Business and Prafesiou Cocio)The Conan ictor's Li. cove law doca not apply as an owner of pmpary who Wilds or improves Overton,and who contracts for such projects with aeunuactor(0 licensed pursuant to the Contractor's Llama law. I sum uempn under Sec. B A P C(ar this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of perjury and afire fallowing declarations: I have and will maintain a Certificate o(Ca veno self-insure for WorkcM1 Compen- sation,uprovided for by Section 3700 of the arbor Code,for Me perlormance of Me work for which this permit is Items. ❑1 have and will maintain Worker's Compensation Insurance,as rationed by Section 371ID of the Labor Code,for we perfarmance of the work for which this permit is issued. My Worker's Compensenon Insurance cv er end Pnumber arc: 'in: Pollry Na.:No CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ' (Thu section need not be completed if fee Permit is Aware hundred dollars(Sla)) or less.) 1 codify Mat In Me iformence of the work(a,which this permit is issued,l shell net employany t any manner ria-To9Ta subeeel the.Workeri Compeuttlan Laws of Ca .Dau "-f Applicant - • - - - NGT[[ ETOAPPLICANT:IL after making a Cenificam of Exemption,you should beWas u m to Nc Workar'a Compenatlon provlaiom of Me labor Cmle,you mmt .J O fn wt imply with such providou m this permit shall W deemed revoked. E"' CONSTRUCTION LENDING AGENCY (.��+ Iberaby affirm than More is a construction lending agency fifer Me parfumamm of CG the work far which this Permit is issued(Sec.3097,Civ.C.) Q Lanced Name z Lender.Address V Q L codify Mel 1 have need this application and sou that the above information is {L t" correct.l epee to comply with all city and county ordinances and sou laws relating to f, building confection,and hereby aufeonne representatives of this city to enter upon Me W abovc-mendoned properly for inspection purposes. G (we)agree to save,indemnify and keep harmlese the City of Cupcnino against ry vI liabilities,judgments,costs said expenses which may in any way seems against aid City C.1 Z, in consequence of the granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCr GUFv CATIONS._/ 5 �' { (�,q}`•L � Re-roofs tum a(ApplicanUConuanor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant dors or handle hrrnrdous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(x)? All roofs shall be inspected nor to an roofing,materia beim installed, ❑Yea 16 No P P Y g g Will Me applicut or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mil hauAnns air cmmaminents as dc0ned by the Bay Amo Air Quality Management all new materials for inspection. District' 11 0y No 1bavemad Mehta rdtwwm=fialsc uimmenuunderChapwr6.95altie Califor ria FicalN&SafctyCadc,Sadons 23303.25577 anJ 25531.1 understand lhuifMc Wilding does fen mmemly hew a unan4 feu it m my mspovihility u ratify the.pant of we immcnu whit mug mm pnorw issuaueofv Ccnifuamof Occya Signature of Applicant Date Owners M"dme agent pate All roof coverings to be Class"B"or better x Community Development 10300 Torre Avenue -40 Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS: PERMIT # © 2 I 5A-�,J T 0-�(2 A 0 q0�( Z �3 OWNER'S N : 11-)-R11 Cin iZcA tit PHONE # 25 'S - 7 9 69 GENERAL CONTRACTOR T)' S PLUwtloi 6 FAX # I am not using any subcontractors: &L-0 qflzC V P:� 5! JP+-, 2- ,P-, _d q- Signature Date Please check applicable subcontractors and 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 TY 5 -P iu M 11.1(, Roofing Septic Tank Sheet Metal Sheet Rock Tile Q SC—P+ - 01 er/Contractor lgnature --Date r CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# 32,5/ .22- a Dc Date: BuilIMM- inAddress: o A N Owner's Nam : Phone#: 4-ug L G Rv-�,Cf A a:53 - 9 8 9 Contractor: Phone Z{ v 8 License#: �' 1� SPLUr�ni3lhly `C254 - 5 Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb Lel Job Description: "i /�, ) QA C Residential E] �1 �"' Commercial ❑ Cost of Project: ppli4ble Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING j BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING