04040025 CITY OF CUPERTINO
OUILDING DISION PERMIT CONTRACTQR I1
VIF0 WA.TTQN
BUILDING ADDRESS: DEBCOR INC PERMIT NO. 040025
OWNER'S NAME: PERMIT ISSUE DATE
DEBCO
ONE: SANITARY 0 6,'2OL NO.
ARCHI'IECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�op LICENSED CONTRACTOR'S DECLARATION Job Des
6 1 Wreby affirm that 1 am licered under provisions of Chapter 9(commencing V NINALSM
n� with Section 7")of Division 3 of the Business and professions Com.and my license is
_Mm mu cera ane effeca WATER SERVICE
- License Class Lie..Dam Con APR 20 2004
DELL
ARCHITECTS DECLARATION
411 1 unMrsunJ my Plms Nall be used u public mrnrN Q n g� Q�
3u Licensed Professional BUILDING
�O OWNER-BUILDER DECLARATION
1 herchy m7fl.The,I am exempt fmm the Contractor's License Law for(be
ZOO following mason.(Suction 7031.5,Business and professions Code:Any city or county -
$ which requires a FCrmil m scam uca alms,improve,demaluh.or repair any mcclum
Fiy prior m its issuance.also requires the applicant fmnuch permit to Ole asigned summons
Ibit he is licensed Pursuant to the provitimm.1'the Commerce.Lim.law(Chmim 9 Sq.Ft.Floor Area Valuatio
$ (commencing with Section 7000)of Division 3 of she Businemand Professions Code)or
that be is exempt therefrom and the basis for that dlcgcd exemption.Any violation of ,;a,p�,} �,.,..y,
Section 7031.5 by eery applicant for a permit subjects the appl{esnt m a civil penalty of 3 081v P 11Mt9r0 0 Occupancy Type
not mom dun five hundred doilas(15(10).
❑1.is owner of tiro property,or my employees with wages u their sole compensation,
will do the work and the mumme is not intended or offered fo...I.(Sm.70a4,Bmirmss Required Inspections
and Plainsmen;Code:The Convince?,License law does not apply m e an owner of q P
porpeny who Wilds or improves ihercon,and whodoessuchwark himadf"through his
own employees.provided tharsoch lmprovemmus ve nal inlercad mattered for sale.If,
however,the building or Improvement B sold within ane year of completion,tine owner.
builder will have the burden of Forcing that ha did not Wild or Improve for purpose of
tele.).
❑1,as owns of the pmRBy.am exclusively contracting with licensed contractors to
construct the project(Sec.70".Business and Pmfadans Code)The Contrumry Li-
mum Taw does not Imply to an owner of property who Wilds or Improves income,and
whocommcu fo ch pro'ecmwi ieeonr r(Ulimnmdpunuentmdm C"U.cmra
Littre Law
tan cam lis c, B&P C for this won
EL'S COMPENSATION DECLARATION
1 hereby vRnm under penalty of perjury arnaf the following declarations:
❑I hvas and will for by Se CeN3nm of Consent"Coca,fur foe Wartrr'a C,of the
cation,r provided for by Section 3700 0(the Labor Cade,far rite performance or the
work for which This permit is issuM.
O 1 have and will maintain Worker's Compensadon Insurance,as required by Section
3700 of me Labor Code,f"the performeme of the wart for which this Fermis is were,
My Workcfs Compensation Insurance artier and Policy number ere:
Center: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseniem need sol uncompleted if the permit is forms,hundrvddollen($IW)
or csa)
I certify that in the performance of the watts for which this permit Is issued,l shell ma
employ any person in any number in as m become subject in the Workers'ComDensaOon
Laws or California.Data
Applicant
NarICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Lehr Code,you must
','Z forthwith comply w W such pmvlsions of this Permit shall W deemed unvotrd.'
?O CONSTRUCTION LENDING AGENCY
[�+ I hereby aliirm that Ncrc is a construction lending agency for the Performance of
C> the work for which this Permit is issued(Sec.3097.Civ.C.)
W 0 Lender's Nemc
z fender'sAIdw
U Q 1"unify Net I have meal this Implication and sum that the above information is
P correct.1 agree to comply with all city and county on insmas and sum laws relating to
�U Wilding construction,and hereby stormier mpre¢nulives or this city to color upon the
aMve-mentio"d property for inspection purymex
agree to
F['+4 (We)agree aro,indent tree homeless;the City of Cupertino ageimt /
cn Iiabilides,judgmens.costs endo.,.which may loamy way amoce.gsina said City /
C.3 7 in con segnv�n flea ening of this perm'.
1.7 APPLI NT ! gg STANDS AND ILL COMPLY WITH ALL NON
SOU
Issued by: Date
SOU h10N5. IN
(y 7/ Re-roofs
S ore of Ap ImantrContrsemr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
T WIII meapplicanl or forum building accupml mom or handle hvallous material
as dcfiacd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Sacry
Code,Section 25532(.)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Yes tints
WIII the applicam or future building Occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit h"ardous air conuminanor defined by the Bay Ama Air Quality Management all new materials for inspection.
DLurict?
❑Yes Nu
1 have read the h"udnus mvmrials requimmenu undc,Chapmr 6.95 of the Calif.,
nig l3eslth&SafctyCode,Scones 25505.25533 am125534.1 understand dem if the Wilding
dem mol cumin v a arta Net it ls my nsiMlisy u notilj the aaupant of the
reyuimmcno hie realism aoraCcnificate ro" ry. SignatureofApplicant Date
or that r<alegaml Dam All roof coverings to be Class "B"or better
_ l
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`UPEkTINO
Building Department
JOB ADDRESk ( 3 S IT#
S s�9.e o ogoo2s
OWNER'S NAME: L--P cope PHONE # MS— £s 3 /5
GENERAL CONT CTOR: FAX #
I am not using any subcontractor" Y
Signature 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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ne, ? Signature Date
01TOFCITY OF CUPERTINO Z
REPIPE/SEWERS/MAIN SERVICES tz�
CUPETI� INO PERMIT APPLICATION FORM
APN# 0 'rP -�7- �OS Date: 41-,
Building Address:
/ S, STEZLI .��
Owner's Name: Phone#:
])c16cole //VC yah-g3� -is30
Contractor: Phone: License#:
OW-MA
Contact: Phone: Cupertino Business License#:
(!H)`f,e0
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Q--
Job Description:
Gc f
Residential p/ `— o rcial ❑
Cost of Projec ,6
Qty. if
A lic e Fee ID Fee Description Fee Group
PPERMTTFEE 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
z-6
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