03050045 CITY OFCUPERT[NO � �'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDINCADDRFss: AMERICAN RESIDENTAIL SERVI EBIdIT"D.03050045
9rt:;j; sTmmp OAK TN
•OWNER'S NAME: 1479 BERGER DR P ITk bT712/2003 r
RBOD ARAM
NE: (408) 287-2165 SANITARY NO. CONTROL NO.
ARCHITEC,`ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
p
Y00 LICENSED CONTRACTOR'S DECLARATION Job Description
�¢+ I hereby afllrm that 1 am liana um r provisiOman'a pier 9(commencing p
n•e with Sectio ] )of Dividon3 of M,Bu' and Profcsslou Codes.end myllccns is
<� mmnmtt 2 EPAIR DRAIN LINE Q .KTICHEN/MA N
;g? LlccnuC lAc.Y �pf FWXLEG
Date Co l.r ,C
ARCNIIECTS 0 RATION
1 u .it.
J my plats.hall W tea public mese,&
Licensed Professional MAY 1 3 2003
OWNER-BUILDER DECLARATION
ni I hereby ahem Net 11. exempt from the Contractor'stCoLiana law for the
OO following mama.(Section]onstruBosinessand improve.
iCale:Mycityseraunty BUILDING
$9 which requires•permit to wrmsuct,alts,.Impmw,demnluh,or repair any stm=wm
prior to its issuance,also requires be applicant forsuch permit file a signed sutsmenl
m�m�S< that he u licensed pursuant the provisions of the Contractor's License Law(Chapter 9 Sq. Ft,Floor Area $ �I®tlOn
2 $ (commencing with Section 7000)of Division 3 of the Business and Profusions Code)ar
i�i�'• Net he u cumin sharefrom and the bub for Ne alleged eumptlon.Any violation of
Schon 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of 3 41?ffii90@*er0 O Occupancy Type
not mom Nan five hundred dollars(5500).
0 1,u owner of the property,or my employees with wages is Nab are cmmpenssUon,
will do Ne work,and the stsuctne is Intended or offered Waste(Sec.]O41,Business lub —
and Profession,Code:The Comrmurs License U.dots net apply to m owner of 2 02 - UNDER VpectBIons,
G
property who Wild,or lmprovesmarcon,and whodoesmeh workhimalforthrough his
own employes,provided thauuch Improvements are mulnurmed oroffared forale.If. 301 — ROUGH PLUMBING
hove..,.the building ser improvement is sold within one you of rompletiom.The owner
Wilder will have the Widen of proving that he did net build or Improve far purposes of 302 - TUB & OR SHOWER
.1.1. 502 - FINAL PLUMBING ENERGY
0 I,u Owner of the property,am uelumvety contracting with licensed contractors to
construct the pmjmt(Sec.7W.Business and Profeaiou Cade:)The Coracures Lb 506 — GAS TEST
cans Law dons not apply to an owner of property who Wilds or improves thereon.and, 507 — FINAL PLUMBING
who contracts for such projects with a contnnor(s)licensed pursuant to the Comractob
License Law.
0 1 am exempt undo Sec. .B At P C for Nb reamn
I
wner Data
WORKER'S COMPENSA71ON DECLARATION
I hereby aBlrm under Penally of perjury one of the following declaretians:
I haw and will malmain a Certificate of Conant to self-Vire for Work es Compan.
on,u provided for by Section 3700 of Me LOW,Code,for the performance of the
rk for which this permit is issued.
1 haw and will maintain Workers Compensation Insurance,a required by Section
00 of the labor Code,for Ne parfmmanee or tiro work for which this permit is issued.
y Workers Cmn,xma ton Insunntt airier an'it Poiricy'l umber are:
rier'.`2LkAd/kjQv�a71MV1 Pul✓Y/. CERTIFICA7EOF EXEMPIONFROM WORKERS'
COMPENSATION INSURANCE
(Thu action..it not be,ompleud If the(xisch Is intone hundred dollar(5108)
or lea.)
1 cenify Nat in the performance of Ne work for which this Permit u issued.I shall not
employ any Nixon in any manner an as Or become subject to the Workeri Compensation
Laws or CaBfomis.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Escreption,you should
become subject in Ne Workers Componation provisions of the labor Code.you mum
,JZ foMwithcomply with such provisions or this permit shall he deemed revoked.
zO CONSTRUCTION LENDING AGENCY
E.. 1 hereby aflbm the them is a construction lending agency for Ne performance of
a> the work for which this permit is m.ed(Sac.309].Civ.C.)
{[7 Q lender's Name
Lender's Add.
U O 1 cenify Net T haw rid this application and suits that the above information is
IL correct.I agree to comply with all city and county ordinances and sub laws totaling to
O SL^J building construction.and hereby auNorre representatives of this city to cnur upon the
(bl above-mentioned property tar impaction p.ryases.
G (We)agree in ave,indemnify and keep harmless de City of Cupertino against
y
liabilities.judgments.costs and expenses which may in any way emus against said City
U in consequence of the ganting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by: Date
OURC ULA77ONS.
e/dS Re-roofs
n uM.f App candCtnuctor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupmt mom or brindle has Noes material
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
ate,Section 25532(x)? �"" All roofs shall be inspected prior to any roofing material being installed.
0 Yu
Will the applicant or future building=open,use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hamodous air conuminsn s u&food by the Bay Arca Air Quality Management all new materials for inspection.
District?
0 Yes )fNo
I have mad the hasardou maurlals mquimments under Chapur6.95 of thc Califon
nia Hca)th&Safcry Cao,5cctiom 25585.25533 md25534.1 undcrsund tha if the Wilding
rims not curtamly hew a tenant.that it u my remormihitiry to 'y Nes .pant of the
'mmcnu wIt h�mustWmclpriortuissumaafacc ' ctea = =y S ignature of Applicant Date
owner arms alive-
,gam Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO 3
REPIPE/SEWF�RS/MAIN SERVICE
•CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: Phone #�
Z--7Z 0
Contractof: Phone: ��� / License#7 �2
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Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: y� )J
/C /
Residentia Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
q?E& PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFDCTURE 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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