05060052 CITY OF CUPERTINO �" p'hs '%' p � ��sa
BUILDING DIVISION PERMIT ,t, UNy T1�A.C +p'R�TN 'O Nly.
.F Yw.A:, R: kEW
BUILDING ADDRESS: WATER QUALITY PLUMBING PERMIT N005060052
tANDRRWR A-1-7
WNER'S NAME: PERMITLSIIEDATE
NE: SANITARY O. iftOL NO.
AR CHITECT(ENGINEER: BUILDING PERMITINFO
LDGO ELECT PLUMB MECH
O
3o6 LICENSED CONTRACTOR'S DECLARATION Ib Description
1 hemby affirm mOIp
at 1 am licensed under provisions of Chapter 9(Commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my liccrec is
m mB ro.a and
__Nz LicenmClam Lic.a ' REPIPE (COPPER INTERIOR)
z Data Comnnor
understand
DECLARATION
1 undernd my plans shall be used as public reenNs /
Licensed Professional C ?fJoG
OWNER-BUILDER DECLARATION +!
gs I hereby 41Brm that I am exempt from the Contractors License Law for On O
i CI o followingus
reaann. tion 71OI.5,Biness Pw,d Rofessiuns Code:A city on County
$Pi which acquires a m it construct.altar,improve demolish,or m it an structure
S2 prior to in issuance.also requires the applicant for such Permit o file a signed statement m
that he s licensed pursuant to the Provision,of the Comncus's License Law(Chapter 9 Sq.Ft. Floor Area Valoat on
5 (commencing with Section 7000)of Divsion 3 of the Businrmand Professions Cede)or
.. that he s exempt theefrnm and the buts for thAscription.My violatioe alleged en of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty of 3�gro O Occupancy Type
not more than Rus hundred dollars(5500).
0 1.u owner of the pmperty,ser my employees with wages u their sok Compensation,
will do the work,and the structure is not intended Or offered for saw(Sec.70th,Business Required Inspections
and Professions Code:The C.mmem rs License Law decd Mt apply man owner of q p
property who builds ser improved thereon.andwho does such work himself or through his
own employee,provided Nn such improaamems see noUnmeded m oBmed formic.IL
however,the building or improvement is mid within an you of completion.the owner.
builder will have the burden of proving that he did nm build or Improve for purpose of
role.).
0 1,as owner of the property,am exclusively Contracting with licensed Conuxmn An
construct the project(Sec.701,Business and Professions Code:)The Comracmh Li.
Came Law dues not apply to an owner of property who builds or Improves maroon,and,
who conuacs for uch projects with a com uelm(O Banned pursuant to due Comrmtors
License Law.
Q l am exempt under Sec. ,B k P C for this reason
Dam
WORKER'S COMPENSATION DECLARATION
1 Mmby aflfrm under pensuy of perjury aneof me following dedand.we
I have and will malnuin•CW 0osmofConsemm selbinsmm for Workee'sCompeh-
jwn,r
ion,u provided fm by Section 3700 of me Labor Cade.for me performance of de
rk for which chis permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
00 of the Labor Code,for the performance of the work fm which ths permit is Issttad.
y Workefa- ompeuatiCo lnmrms-e ccunmandPolleynumI sWgS�,�(y''�rier. * S� z)f Y`K PoI¢y No.:M%00
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Ihh sectimn need not becomplcwd If the permit Is forone hundeAdollan(5100)
or leas.)
1 unify dust in the Performance of the.,it for which this permit is issued,l shall am
employ any pc sen in any Manner an as to meconembject to the Worked Compensation
Laws of Calif..!..Dae
Applicant
NOTICE TO APPLICANT:If,after making this Ceniricam of Fsemptim.you should
become subject an the Wohefs Compensation provisions of due IsMr Code.you roup
.,O forthwith Comply with such Provisions or this Permit mail ed dComed rewked.
�y CONSTRUCTION LENDING AGENCY
[-d 1 hereby,Rum that ft.Is a mvuuction lending agency for due performucc of
a the work fur which this permit Is issued(Sec.309'1.Civ,C.)
ULamices Name ,
Mi Q Z Lender's Address
U Q 1 csnify mm I Mw mad this application and sista this the above imformatiCo 1,
II.^. Cortcca 1 agree to comply with all city and county ordinances and sue lana msting In
17 building construction,and hereby sutholm MPremntmiws of chis city to enter upon the
W shove-mcmtioxed property for Inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino @gout
in liabilities.judgmes,Coro and expense which may in my way acme against said City
U in consequence of the granting of this permit
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by:9102�e&00 Date 6 �-f—
OURCEREGULATTO S,\\ � ^�
a A Cirl'(f Re-roofs
Slgnawmaf ApplicAl/Comocmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Applicant An fumm building occupant mom or handle herardum material
as defined by ih CupcMno Municipal Code.Chapter 9.12.and the Health and Wary
IdomMode.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will de applicant or forum building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
ICtmeffilieh...1cham,�Mit.rnyugA,ons
mit hamrdnus sit contaminants u dcfmcd by On Bay Area Air Quality Management all new materials for inspection.
District? ,..1
Q Yes �No
1 haw read due hmsrdous matadasmquiremcns under Chapmr6.95 of de Califory
im CRI @Safety CWc,S om25505.25533aed25334.1undcmend thatifthc building
uhomenswhicn muuM a wissu of@Ccnilic of OcCo Signature of Applicant Date
4 A '" " �" All roof coverings to be Class "B"or better
wner ser mdulaind&g5u Dae
Community Development
acloF
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
O SO600 S' L
OWNER'S NAME: IPHONE # j r93
GENERAL CONTRACTOR FAX # 14 y
.MQ I
I am not using any subcontractors: 'C
Signa 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
PlumbingaA!az �{� l
Roofing
Septic Tank
Sheet Metal
Sheet Rock
. Tile
/Contractor • ture Date
i
CITY OF CUPERTINO
Gp' REPIPE/ SEWERS/ MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN #35(4�D3DC)a Date: Tta�-
Building Address:
�+.
Owner's Name: Phone#:
n r r� 950 -a9s
Co tractor: License#:
Contact: Phone#:
�pplicant/Contractor:
� '�� l (lr✓I rl . .
Building Permit Info: Ij
Bldg Elect Plumb Mech
Job Description: ep,'p�
ResidentialX cUD c . Commercial:
Sq.Ft. Floor Area: J�V $/Sq.Ft.:
Architect/Engineer: Valuation: 5000 . pp
. 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 PbIg Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
• BUSLIC Business License BUILIDNG
a�- z1 7 37