04110082CITL ERTINO-
slsloN PERMIT
CONRrS GQR iNFOUMATJON77
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BUILDI
PLUMBING
PERMIT NO..CUPERTINO
04110082"OWNER"
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PERMITfESUE DATE .. .._
ONE: - - "' l
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SANITARY OL NO. ,
ARCHITECT/ENGINEER:
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BUILDING PERMIT INFO
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BLDGELECT PLUMB MECH
' - LICENSED CONTRACTOR'S DECLARATION,
-..Job Dtion -
'^ ' '• Description
1 hereby amain that 1 am licensed under.previsions of Chapter 9 (commencing
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with gcclittn 7011nl of Oivisian3of me Businsmd Pmfcuio`nx
on'"'taste and ellen. '=-
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Lim, cl G a' Lo, a ZY
REPIPE
Datacantreebr-,eRf U}l /71G/
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- ARCHITECTS DECLARAR TAS
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. 1 understand my plans shall be used as public mcords
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Licensed Pnn.aionel
OWNER BUILDERDECLARATION -
I hereby alum that am exempt "from the Constants License Law fo rlic
following moon. (Section 70315 Business and Professions Code Any city of county
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which requires a permit to emissions. alter; improve, demolish, or repair any'swctum
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prior In its issuanc ,also requires the applicant forsuch Permit o She a signed statement
that he is licensed pursuant to the previsions or the Commodes License Law (Chapter9
" Sq. Ft..Floor Area
Valua on. -
(commencing with Section 7")of Division 3 of the Business and Professions Cade)or
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that he is et¢mpu therefrom and the baau fdi the alleged exemption. Any violation of
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3 YdMI91V0!9T) 0
Occupancy Type -
Secdon 1031.5 by any applicant for a permit subjects the applicant a civil penalty of
oat moe Nan love hundred dollars (0). , _, . . ••
❑:1. as owner of the property, or my employees with wag. as their sok corepensstion,
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will do the work end theanuctum is not intended oroRemd forsale(Sec. 7041, Business
Professions Code: The Contractor'sLicanso Law
,•
- Required Inspections - -' '
and it= not apply n an owkr of
simmered through Mr:
1
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menpriapertycrowhab,provied tat suhimonandwho RIC machwork
ownemPloyecs,provided met such improvements ere notimmnded or offered fmsek.If.
however, the building or improvement is sold within am year of completion. the owner.
builder will have tiro burden of proving that he did Out Wild or improve fm purpose of
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sale.).
1, as owner of the property, am exclusively contracting wit licensed romnenm to
consumer the project (Sec. 10x1, Business and Professions Cade:) The Contractors Li-
cenaelawdo.ammiplymanowyar of property who Wilda orimpmv.thereon. and.
cuf much Ptv'anta wihaconuanar(s)Iicensed pursuem tome Contractor's
License aw.
pub de' Co. BkPCfR9 isr. ./
WOK O SATION DECLARATION
ereby Wir a perjury ane of the following declarations:and
(371MOf
will maintain a Certificate of Consent to self-inaum far Warkr's Campus -provided
far by Section 3700 of Ne labor Code, far the performance of the
hich thea permit is issued.end
will maintain Worker's Compensetlan Insurance.. myuired by SectionCLaborCode,
for the performance of the work for which this permit is issued.
My Worker' n pensm/i m Insure ce camicr and Policy number wo
Cartier. P heJ /Oe� Policy bki''��
CERTIFICATE OF E%E14Tf10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not keomplmcd If the pcmsit is for one hundred dolkmf$H10)
or l.rJ
1 certify that in to performance of the work for which this permit is issued. I shall not
employ any potion in any main erso as to became subject to the Workers' Compensation
Laws of California. Data
Applicant
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NOTICE TO APPLICANT. If, after making this Ceniricata of Exemption, you sWu15-
became subject m the Workers Compensation provisions of mo Labor Code, you must
forthwith comply wit such previsions or this Finanit shall k deemed revoked.
CONSTRUCTION LENDING AGENCY
I hcmby affirm that there is aco.sucuinn lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ, C.)
Leader's Name
Lenders Address
I certify that 1 have mad this application and sum Nau the akvc information is
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correct. I agree m comply wire al city and county ordinances and state laws misting of
building construction. and he y jtutharim representatives of this city n enter upon the
above-montioned.proper y rim cetian purposes.
(We) a seem m inddm end keep h the City of Cupcnino against
so.
liabilities, it menu, sac soda .. whichm in any way accrue against said 'it
in conuqu cdaf granting this trout.
his
APPLIC U 5 A WIL MPLY WITH ALL NON -POINT
Issued by; Date
SO RE TION
Re -roofs
Type of Roof
Signmum A a ammeter Data
HAZARDOUS TERIALS DISCLOSURE
11 the applicant or future but ding occupantstom or handle harardous material
as define y the Cupertino Mu 'cipal Code, Chapter 9.12, and the Health and Safety
code. Section zs53z(a)?,
All roofs shall be inspected to any roofing material being installed.
o
prior
If a roof.is installed without first obtaining an inspection, I agree to remove
Will the applicant future Wilding ocopant use egatpmcnt or devices which
mit haramour air contammants as dcRncd by the Bey Area Air Quality Management
all new materials for inspection.
Dissin?
❑Yes .� u
Ihavere thehe own smquimmcnuundcrCWpmr6.95oftheCalifor-
nisHeabliAr ctyc ,Seed 2551 and25536.1undersmodmaziftk Wilding
dues n C Coala, ion on, IIS my mspoisihility m notify the oem ant of the
regm m ' i k Ip issayacertinCakarQeal`wlCy.
Signature of Applicant Date
�,
All roof coverings to be Class "B" or better '
C mwuh.nCLd.S1 Dam
120
%I
CITY 0,
UPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
z Zc.ore Sl I w-, -- 615klie
PERMIT #
OWNER'S NAME: nPHONE
# 7-L5-6 Lo6XO"7
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors: ! 5, O '
Si Date
Please check applicable subcontractors d com Tete zein information
Me --
1
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Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
I
Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T
Me --
1
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Date
L
OF
CUPEkTINO
CITY OF CUPERTINO
REPIPE/SEWERSIMAIN SERVICE
PERMIT APPLICATION FORM
APN # Sqz� y�
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Date:
Building A 2Z1?
c lVe � / /
PLUMBING
Owner's Name:
Bldg. Permit Fees
Phone #:
BPFIXTURE
Pbl . Fixture
2s's - Lo 0 C 7
Cont ctor:
V7
Phone:
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License #:
C� 2 `��IUS"
C
ct: Phone:
Cupertino Business License #:
Building Permit Info:
Sewage Disposal
PLUMBING
Bldg❑
j
Elect El Plumb COY
BUILDING
Job Description:
Residential
Commercial ❑
Cost of Project: \
Qty. if
Annlicahle Fee, M
FAP nPC/Y111I'�l�n
T7eo n.
PPERMITFEE Is—
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Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
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