03070048 r CITY OF CUPERTINO yT '� }'•� �� '_" '
BUILDING DIVISION PERMIT i,11CONTRACTOR INFORMATION,
Bua (408) 995-6400
omcnoDRess: GREAT AMERICANA PLUMBING CC PCD 03070048
• OWNER'S NAME: 166 GRAHAM AVE PERMULSSUEDATE
ONE: SANITARY Nrt� CONTROL N0.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Z, LICENSED CONTRACT'OR'S DECLARATION' IOh DCSCrIpIIOn
uF 1 hereby affirm that I em licensed under provisions of Chiper 9(commencing
¢W with Section 7000)of Division Saida,Businessand Prufessinnx Code,and my license is
^< in full force antl arifte
Lie,n el,.� e .ale Lm.« lhol REPLACE SEWER LINE
^p Date 7- d4 Comracat fYWe I 0
p�IJ' As%hall use DECLARATION
Jul-
0 Z��3
?Wu 1undersand my plans CHITiusedupublic DECLARATION
L
th Licensed Professional
g OWNER-BUILDER DECLARATION
<X 1 hereby affirm that I am exempt from Ne Contractors License Law for the �p 'WING
E:
m
p O following une.(Section 7031.5,Business and Professions Code:Any city at councountyV
a
e m� which r.quiref a permit to eonsuact,alter,impmw,demolish,or repair any suuetum
m^sa prior to its issuance,also requires,lad,applicant rat such Permit to rile a signed statement
Tic that he is licensed peasanuathepmvisiovoftheCharacterilai n
License Sq. Ft. Floor Area Valuat
erd-cl (commencing with Section 7")a(Division 3.(the Business and Professions Code)or
.. that be u exempt therefrom and the bun for the alleged exemption.Any violation of
Section 7031.5 by any applicam for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nm
en five hundred dan(i500k pane y yp
C 1,as owner of the progeny,or my employees with wagesas their sop compensation. �����r�'
will do the work,and thuwcture is amt intended or offered I...1.(Sec.7W.Businea 106 - SEWER R$; IlrfAJUi3ections
and Pro(.aions Cad.:The Connectors U.Law does not apply to as owner of
property who builds.,improves themon,ad who decs.uca work himalforNmugh his 202 - UNDERFL OR PLUMBING
awn emPlaydes,provided that such ireprovem,nu amnatintended oroffaad Nr a le.if. 3O1 — ROUGH PLUMBING
however.the building os improvement is sold within.ne Ku of completion.the owner
buimwill baw th,burden of proving that rte dm a.,Wild or improve Iw partial of 507 — FINAL PLUMBING
ale.)„
❑1,a owner of On,property,am exclusively contracting with licensed cmnuectara 1. -
consumer the project(Sec.704.,Business and Profusion,Code:)The Contractor's Li-
ceve law does not apply to a owner of property who builds or improves thereon,and
who contracts for such projeau with a eontncum(s)Reeved pursuant to tk Contractor'.
License Law.
❑I am exempt under Sec .B&PC for this much
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby M.under penalty of perjury one of the fallowing declarations:
1 have and will..main a Cenifiate of Cove..self-i.acm for WorkeM1 Compere.
inion,as provided for by Section 37W of Ne labor Code,fm the poformanm of the
.,it for which this Pcamit is issued.
C T have and will maintain Worker's Co aMnanion Insurance,u required by Section
37W of the tat nr Code,for the performance of the work for which this permit is issued.
My Walker.Compensation Insurancemhe
carrier and Policy nurnnart:
Cartier. 5Tiarc FWAJO Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tbasee ina seed not acemnNoted Iris,permit is formal hundred dollars($HxB
or less.)
I certify Net in the pcofor mance of the work for which Nix Permit is isswed.I shall not ,
employ any Nixon in any manner so as to become subject to the Workeri Compersuion
Laws of C.lifomia.Date
Applium
NOTICE TO APPLICANT:If,after making this Ceririca¢of Exemption,you thauld
become subject to are Worker's Compensation provisions of the labor Code,you must
.JO forthwith comply with such provisions or this Permit shall h deemed toward.
CONSTRUCTION LENDING AGENCY
'Fr I hereby affirm Nal there to ronnmction lending agency rot he performance of
(x 7 the walk fur which Nis permit is issued(Sec.3057.Civ.C.)
tact Q Lender's Nero, '
Z Leader's Address
o
V Q 1 certify Nat 1 haw read Nicety and County
and rote that theand above ws relating is '
0 ,^n cording l agree be comply with y tidy and counry aNinaceaeis sole laws reprint to
pU ahow-nmoniwctionand hereby auhonprcprescnudivu of Niacirymcnmr upon the
�"a ,hove-(We) axid gree to amrty for inspection
mnify an keep es.
(We)agmen do cove,indemnify and kith harmless the City of Cape
againsts id City
F' h liabllilic¢,joddmenn.costs and expenses which may in any way a<csuc gains said City /�.
0..37 in inn u.ncc of the tan t nd of this permil, `/-L',!�)/7/ 2,
APPL ANi UND NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ERE L 9 �(;a
V` , Re-roofs
rte col mract
PlunioVCoot Detc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant Imre or handle hautlous materiel
as defused by the Cupertino Municipal Code.Chapter 9.12.ad the Health and Safety
Code.Section 25532(.)7 All roofs shall be inspected nor to an rGofin material being installed.
C Yet XNo p P y g g
Will the applicant or future building occupant uxryuipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,it ha'ramon,air conmmimnts u defined by the Bay Area Air Q..lity Management all new materials for IDRpeCllOn.
i¢trict7
❑Yds KNo
1 have mad Ne hanaNnus materials requirements under Chapter 6.95 of the Califor.
nia licalth Safely Codc,Sections 355115.25533 end 255.1.'y dcntutd Nedif th.buildind
dark no[' r emly w,a t n .t id is ry reoponsimaly m no�d]y In nrcup.nt of the
m alrcmc awhi rook` t;."ai.m aEYNB6teofObsppency Signature of Applicant Date
�^7^k-o 3 All roof coverings to be Class "B" or better
Ow crd and aHzed agent Data
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CITY 0
CUPERTINO PERMIT APPLICATION FORM
APN# l Date:
Building Addr
o � S Ncs
Owner's Navlf. — �f�'✓11Y/ `Jmoi, p253"y 1-7.7
Contractor: hone: Lidense#:
lCAQ Lwti. /D$_� S �l00
Contact: Phone: Cupertino Business License#:
JU,�
Building Permit Info:
Bldg ❑ Elect ❑ lumb
Job Description:
e L Sia (-iAUc
Residential Commercial ❑
Cost of Proje
3�600°
Qty. if
AppIrcipble Fee ID Fee Description Fee Group
PPERMITFEE 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