05060053 CITY OF CUPERTINO h ';*" s+w:a .T, F + --
BUILDING DIVISION PERMIT ��1N,%T12 C�tT 4NF'U5 IATIQN `_
BUILDING ADDRESS: WATER QUALITY PLUMBING
PERMITNO
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY O. CONTROL NO.
ABC
HITEC MNGINEER: BUILDING PERMIT INFO
BLDG 0 PLO lMECH
�
6 LICENSEDCONPRACIOWSDECLARATION JobDescri tion
i� I herby affirm lost 1 am limned under provisions of Chapter 9(commencing p
i with Section 70111)of Diviriren J of the Business and ProfcuiomC IM my filen is
<� mrm.Clma.
md ;LTT\ REPIPE & REPLACE WATER HEATER
5�? LiccnsuC s Lic.N Vw
if-- Dam Canmaemf COPPER INTERIOR U�
0 q ARCHITECTS DELLA r ION A tl.a r` fn
I undcuund my plans me he used a puhlic rccnrds
D i
G Licemed Professional
s'y Oat I am BUILDER DECLARATION
CommeON Y [
1 hcrthy v(Sect Net 11. exempt from the Conuasmlo License Law for the 90 ZOO5
F.00 whichfollowing Rstaa.Permit
i BHLS, t.slam{and Professions Cada:Any sm Or county
ante GG��
$ which requires•permit inconstruct.t,alter.Improve,h PemW,we a signedtwment _
Fly thiwmiuutuam0.aharcquirhe thcapp0canr for suchpctor'lLicams Law V
F G (Comm Blkn With
pucmant 70th)provisional of theContractor'sBusiness
Limnmisw(C Code)
Sq. Ft. Floor Area U Ilya VdIUB- 400
that he Is
(Commencing with Secifirom it ofbasisDivision l the
Ne Busineeand Professions Cade)of '7=
..
that he ts exempt sherefrmm and Ne bah far the alleged emmption.Any violation of J L II��a`
Section 7071.5 by any applicant for a permit subjects the applicant in a civil Penalty of APN Number Occupancy Type
not mom than five hundred dollars($500).
❑La,ownerofthe property,army cmployces with wallows Neirmleeompentadon, 35604017 . 00
will dodos work and the s"turn is not inunded oroRsrtd forsele(Sm.7044,Basins
and Pmfcsslam Code:The Convacmfs Limine Law dins not apply to in owner of Required Inspections
property who Wilds orimprove theram and whodmainchwork himselforthrough his -
ownemployes,pmvided6atsuchimprovemenssarenmimm.dr4wonemd(wr lf.
however,the building or improvement 4 mid within am You of cemplcdon.the ownor.
builder will Mw,the burdm of proving dust he did not build or improve for purpose of
sold.).
❑1.as Manor of the property am emimively contacting with]!meed conmmuma to
com n ct the project(Sec.7014,Business and Profession Cade:)The Compasses Li.
cense Law dare not apply to an owner of property who builds or improves themon.ad.
who contracts for such projects with a com momrO licensed pumoant to the Conummes
License Lew.
❑I am exempt under Sm, .B&P C for this resmn
wner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby,affirm under penalty of perjury ane of the following delwions.
1 have and will maintain•Cerifeme ofConsam m self-imu a for WonmesCompen-
mtlom.a provided for by Section 7700 of the Labor Code.for the performance of the
work for which this permit is Issued.
❑1 have ad will maintmn Worker's Compensation Insurance,as myuired by Schon
5700 of Ne Labor CMM,for the performanm of the work for which Nie Permit is Wood.
My Worker.Compensation Inssnm ca r and Policy number talM:gqW
Ceder. Poll
EJ(EMey
RTIFICA •OFITION FROM WORKERS'
COMPENSATIONINSURANCE
(Thusection reed not be completed If Ne permit is foram hundred dollaa(5100)
or fuse)
I unify that in On performance of the work for which Nil permit u issued.I shat]not
employ any person In any manner an as m become subject to the Worker!Compemadan
Laws of Celifamia.Dam
Applicant
NOTICE TO APPLICANT:Ir,after making this CemOcam of Exemption,you should
become abject to the Worker's Compensation provisions of the Labor Code.you must
O O forthwith comply with such provisions or Nmis M i shall be duemcd revoked.
'Z ..
„ CONSTRUCTION LENDING AGENCY
y
(—r 1Mseby arfne Nn Nem Is a caruuucdon funding aRney,for the Performance or
(Yi> the work for which this permit Is Wood(Sec.5097,Civ.C.)
L0 Lender,Name
=z Lender',Address
U Q I cerify that 1 have read this pplication turd slow that the show Information b
ilr^ cormm.l agree Or comply with all city and county ordinances and sum[am mining m
Q SU' building convection,ad hereby euthorim mpmanutiw,Of this city to Omer upon the
Liz above-mcndoncd Property for inspection purposes.
(We)agree to ave,indemnify ad keep harmless the City of Cupertino against
r
IA labilitlu,judgmemu,costs and expenses which may In any way acme against aid City
t)7 In consequence of the granting of this permit.
Fi APPLICANT UNDERSTA ILL MPLY WITH ALL NON-POINT Issued by: Date
OURCH REGULA t/�
C ,A ` I Re-roofs
Sltnuwe(TrApplicadiffrommilmor Dam
HAZARDOARDOUS MATERIALS DISCLOSURE Type of Roof
Will doseCuentser future WildingOccupantChaptswmorand Health and
u de0ued by the Cupenlna Municipal Code,LTaPmr 9.17.and the HcaIN roti Safety
ada.saedamzss5z(.17 All roofs shall be inspected prior to any roofing material being installed.
❑Yeo
Will the.:pliant or foam building m:uPam use equipment or denim,which If a roof is installed without first obtaining an inspection,I agree to remove
Smit harsrdnua air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Distric97_E]Ye. �No
I have mad the Weardws materials requirements onderChapwr495ofthe C.lifom
all Health&SalnyCodc,Setiau 25505.75555 and 7351/.l undentaM lou franc Wilding
does not currently have a u n m.Wt it as my a ihility m notify the occupant of dos
mjg�m(remcnta which mum van fir,certificate ofocswaney Signature of Applicant Date
ownerora NS� m (nC All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
&CO Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDS-71RESS: Sr' PE O a 600 s'3
OWNER'S NAME: ►NM @ Cd PHONE# _g
GENERAL CONTRACTOR FAX# Co
IF, a
I am not using any subcontractors:
St ature 7 V1Date
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 V*0!MQ—Q HW 4Z41
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signa a Date
M IOr CITY OF CUPERTINO psis S
REPIPE/ SEWERS/ MAIN SERVICE
CUPER,TiNO PERMIT APPLICATION FORM
APN #�t O , (9/7 Date:
Building Address:�Ya(/p�3
Owner's NamePhone#:
V8
tO o q3
Contractor:` /�✓✓���/ License#: J /
Contact: �y Q� Phone#:
Applicant//Contractor: (1
Building Permit Info:
Bldg Elect lum Mech
Job Description:
Residential: \ Commercial:
Sq.Ft. Floo Area: 21o0 $/Sq.Ft.:
o
Architect/Engineer: Valuation: 5Y O D cY0
• Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issue PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pblg Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
43 r4=!. \v
1� BUSLIC Business License BUILIDNG
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