03050075 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Kc WAACTOR
BUILDING ADDRESS: WILLIAM & PEGGY BODENE PERMIT No.03050075
DR
OWNER'S NAME: PERMIT TT 16/2003
NE: SANITARY NO, CONTROL NO.
ARC HITECTYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
io0 LICENSED CONTRACTOR'S DECLARATION
1 hereby Affirm Nal I am licensed under provisions of Chapter 9(commencing Job Description
who Section 7")ofDlAsk n 3.(the Business and Profession&Code,and my license le
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in fullandercmL STREET CLEANOUT FINALEO
Lleelllt noccl�laa 1x.1
-I;- Data Contracts,
ARCHITECTS DECLARATION MAY 2 0 2003
1 1 understand u re
and my plana shall rm need public cords
)y
upLicensed Professional
OW NER-BUILDER DECLARATION
JBUILDING
< air,.1 hereby athat I am exempt from cite Conlracloes License Law for the
p O following recon.(Section 7131.5,Business and Professions Cade:Any city at county
<$E which rectum a permit to contract.alar.improve.demollth,or repair Any stsucturn
uZl+n prior an is issuance.also requires the applicant for such permit 0 rile a signed statement
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that he is licensed pursuant to We previsions of the Contncmr's License Law(Chapter 9 Sq.Ft. Floor Area Val �lOn
222 O (commencing with Section TOW)of Division 3 of the Businu&and Profusions Coca)or �rY'
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that he is exempt therefrom and the basis for the alleged exemption.Any Nolmian of
3 Sued.7031.5 by any applicant for a permit Nbjeeu the applicant taa civil penally of 3 AM I4tIIt)bej t 00 Occupancy Type
non man man five hundred dollars(f5W).
❑I,a owner of firm pmperty,or my employees with wage as their sole compensation. �y;
will do the work,and da swmure is notintanded oroResed for We(Sec.70/4,Business — ER 1sq 1 ections
end Pmfealons Code:The Contractsr't Liaise law don ml apply b an owner of 2 02 - UNDERFLOOR PLUMBING
property who builds or improv memon,and who does such work himself sur trough his
own employees,presided tharsuch Improvements are not Intended mnRered for ale.If. 301 — ROUGH PLUMBING
however,the building or Improvement iasold within am year o(compledon.the owner
bull&,will haw the buNcn of proving that he did mt build or improve for purpoa of 507 — FINAL PLUMBING
ak.).
❑1,Aa owner of the property,am exclusively canoaeting with licensed cnntractsn to
construct the pmjea(Sec.7044,Business and Professions Cade:)The Contrm b s LI-
ceue law does not apply w ml ower,of property who builds or improv thereon.and,
who concocts for such pmJtcts witha contractor(s)licensed pursuant ts de Contractsr's
rwase Law. -
lamez.ey(m/sl under Sea .B k P C for this numb
Ow ✓"�n�--�.. Data 1 b—0
WORKERS COMPENSATI N RATION
I hereby mfim under penalty of perjury am of the following deolacedom:
I haw and will maintain e Certificate of Consent M self-alum for WoftelCanpen-
adon,as providmd fm by Section 37W of da Labor Coda for the perfam u ce of me
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance,n required by Section
3700 of the labor Code,for the Performance of the work for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number me:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scedm need not beeomple¢d if trm perms(is Intone hundred unit=(51 W)
car kis.)
1 cenify that L c performance of the work far which this Permit Is issued.I shall not
employ any peso ' rc! A bmplpllab a the Workers Compcuadon
Law of Celifa L
Ap Ice
NO10n TO APPLICANT.the r'e'er making this CmniOua of Exemption,you ushould
an"
become subject ts the Worker's Compensation provisionsiai of me labor Code,you muss
.J 0 forthwith comply with such provisions or this permit Nall rm domed revoked.
„z,i CONSTRUCTION LENDING AGENCY
y
[+ IMmby aRm that there is a construction lending agency for the perfumance of -
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the work(tar which this permit u issued(Sec.3097,Ci,C.)
12
W Lsndc Name
a Z 0 1 lender's Addmu - -
V Q 1 certify that 1 have rad this application anal sus Wt he show inform W un Is
I7. comm.1 agme to comply with all city and county ordiunces and state laws mating to
O t Wilding construction.and hereby Authones representatives of this city to enter upon the 07
r U5 ah.w.mentioned property fa inspection purposes.
Q. (We)agree to taw.indemnify and keep hamlm the City of Cupertino apart
F'rA liabilities,judgments,come send expenses which may in my way amue against said City zz
C.37 in comer coee of Ne granting of this permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S(OnE G� ULATIONS. �'rk '�
�� �l-��, `-l/ Re-roofs
Bute tum oI`AppI uaVCW..r Data
Sr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building occupant store or handle huardous material
a defined by the Cupenina Municipal Code,CWptar 9.12,and the Health and Safety
cede,Section R�"°I All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it herardnua air contaminant as defined by the Be,Area Air Qumity Management all new materials for inspection.
isviaT
❑Yea Nu
1 have read the hsrardw&m tumah tequitammms under Chapter 6.95 of theCmiler-
meHulmkSafnyCWa.Sava¢25505.25333 and 25534.1 understand this irk building
does not currently ham a mmnL that it u my responsibility to madly that occupant of the
Immmmn which mutt he met poor ts issuance of ac mats sur Occupancy. Signature of Applicant Date
s
ower,or WIWflxad agent Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
REPI.PE/SEWERS/MAIN SERVICE 0305'"
:CUPEkT`iNO PERMIT APPLICATION FORM
APN# Date:
LAO - 0 0-1 _ 5 - i Io 0 3
Building Address:
Owner's Name: Phone #:
Lk 0'6 -b-13 -zS-19
Contractor: Pno—he License #:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 19
Job Description: l
T-
Residential Commercial ❑
Cost of Project: yy LA
Qty. if
Applicable Fee ID Fee Description Fee Group
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 Energy BUILDING
BUSLIC Business License BUILDING
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