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CTTY OF CUPERTINO,
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�CUNTRe�CTOTisIN'T3M'AT�g11T-
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
BELL PLUMBING INC
PERMIT N%4020106
OWNER'S NAME:
PERMIT ISSUE DATE
*OL
ONE:
SANITARY C NO.
AR CHITECnENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 herby affirm Nal Tam li¢asod under provisions of Chapter 9 (commencing
with Sued.. 7W) of Division 3 ofthc Business and Pr wions Code. and license is
run eRett
ri
torte ens
uansereem C t Ua& ri- %Y'
INSTAL SEWER FROM HOUSE �� +EP``[G NE
AF
Dau' Con
e
ur L
! - ARCNr1EC1'S DECLARAT ON /
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undersunJ my plain
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FEB 1 7 2004
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Licensed Pmfcrei... I T — i/
AWNER-BUILDER
i
� DECLARATION
��.I hereby, am. that 1 ma excmptsmm'thd ComrarYs license Law far rhe
Io
foRlnj!e O.(Salim1031:5,BupinessandPmfmomesCode:Any city orcounty
BUILDING
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which meal.�a7pormiCta cdn-,OCL aper. improve: demolish, Or Trish my awmum
;y
PH., m its issuance. elan requires Ne applicant for such permit to file a signedtatement
COmosetr'a Lignac MW(Chapm 9
Sq. Ft. Floor Area
Valuation
Oat he is licensed pursuant In Me provisions of lM
t $
(commencing with Section 7000) of Division 3.f the Budneas ood Profeuiaru Cron) ter
that M u exempt therefore. and dte basis fm the alleged exemption. Any Anhdon of
3 -y it�ero o
Occupancy Type
Section 7031.5 by any applicant fora permit objects the applicant o a civil penalty of
trot more this fm hundred dollars (11500L "
❑ I,MvOfthepmpmy,mmymploymwlthwgea.NeUwlecompewdon,
Required Inspections
dothewowk, andth 7o M. Businw
an,
Law&ply.
and Professions Code: The Cantramts License law don weak appty If an owner
and The Commons License
q P
nigh his
property whom. Ida or irepmvu chimer, and who dmuuch wink himulf is
ed f
ownemployees,pmg improvements aremt for WeIL
year ofdmOEered
the building car I.o sold within one )ear Of completion, the awnen
or i prover
provinis
sultan will Mw the Wrdm of proving No he did nor Wild m Improve fm puryose of
wilder
role.).
1, u Owner of the property, am reclusively connecting with licensed mntramta to
construct the project (Sec. 7044. Business and Profusion Code:) The Container's U.
cease law don not apply m an Owner of proper who builds or improves Mccon, and
who contracts for such projects with a eonuaeror(s) licensed pursuant to then Contractor's
License Law.
C i am uempt under Sec . B k P C (are this roan
ner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aloin under penalty Of perjury ane of the following declaradome
1 have and will maintain a CeNficate of Consent to self-Insure for Worker'. Compen.
ion, as provided for by Section 7700 of the Labor Code, for the performance of the
IC33"737.,W
eak for which this permit is Issued.
1 have and will maintain Worker's Competuadon Homes, as required by Schon
of Ne Ube,care.for the performance of Ne work far which this permit is Issued.
Warkefaciernpensas lmwuran9cartiere Po cv. diem.Tar:
rtier: Iry No.:%lr=
CERTIFICATE OF E%EMMnNFROM WORKERS'.
COMPENSATION INSURANCE
(This sceflm recd not bin completed lithe Mono, Is fora.. hundred dollars(3100)
or less.)
1 certify Nat in the performance of the work for which this permit ts Issued, I shall at
employ any person in my moneran m m become subject to the Workers Compensallon
Lawsofcalifomia. Dar
Applicant
NOTICE TO APPLICANT: If. after making this Cenifmnc of Exemption, you should
become subject to Ne Worker's Compensation provisions of the labor Code, you must
.
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forOwirh comply with such provisions or this Permit be dam.d revoked.
Q
CONSTRUCf10N LENDING AGENCY
a^N.n
I hereby eRum that Nem is a coasWninn lending agency Ins the performance of
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the work for which this permit is issued (Sec. 3097. Civ. C.)
ALender's
Name
z
Lender'sAddress
'1
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1 certify that 1 have rad this application and alar that the above Information is
caracc4l agree to comply with all city and county oNinmces and elate laws misting to
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building construction, Ona hereby oNorio representatives of this city o enter upon the
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above-mendoned proper for Inspection purposes
(We) agree to save, indemnify and kap hoolers the City of Cupertino against
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liabilities,judgmems. costs and esp. which may in any way emrm.pimn mid City
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in cortsegucnec of the ¬ing of this permit.
APPLICANT UNDER STA DS D L COMPLY WITH ALL NON-POINT
Issued by: Da
SOURCE E ULATIO 1—
o
y;Re-roofs
iBhat of Ap li wcmr Dale
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occ.pra mom Or handl.Im mous mauaitl
m defined by the Cupertino Municipal Code, Chapter 9.11, and the Health one Safety
am. Section n5324)7
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant car rum. buiidi Occupant use equipment or devices which
it haramnn air comuminints m recd by the Bay Arra Air Quality Mma,morn
all new materials for inspection.
isu icR
❑Yeso
I have rad die Maawdeus materials requin mems under Chapter 6.95 ofMc Cali(or.
nia Health& SafctyCOdc.Soedou 25505.25533 and 15534. Imacrsund Must (the building
Jun not cuneoil, ham a tenure that it la my maponthilily notify Me occupam of Me
requirem tswmmhma pre lar sane es '0
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Signature of Applicant Date
l
All roof coverings to be Class "B" or better
Tar solos < serer Date
171
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS.
PERMIT #10�� a
a ua.uvia..�
SUBCONTRACTOR
T
OWNER'S NAME: -
PHONE #;ZS
GENERAL CONTRACTOR:
EAU
I am not using any subcontractors: v
Signature Date
nnA romnlete the following information:
1 1cGJC
Ulcl.[�
a ua.uvia..�
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
ner/ Contractor Signature
10/28/03
Date U�
11
1
CITY OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
r
APN # 2) — 5e� O C)
Plumbing Permit Issuance
PLUMBING
Date: —
l
Building Address:
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
3� s
PLUMBING
311
Main Water Service
PLUMBING
Owner's Name:
Sewers
fPhone
, 408'
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
Contractor:one:
License #:
bin
'510)
�3tf 5000
-)-Y 7
VO
Contact: L Phone:
R0�J2
`i 0
Cupertino Business License #:
- —7o-\ o
/08'7
00"`/
Building Permit Info:
Bldg ❑ Elect ❑
Plumb
Job Description: t55 c a -k c-�I —13
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5 �q r (vi I ^r v`� A 7 X ! . � � 1 I-rc, v
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U 7 ler
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Residential ommercial ❑
Costo roject• � � �
Qty "
An r le Fee TD
Fre ilrcrrintinn
Pa. i:rnnn
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
2 03-
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