03100038 . CITY OF CUPERTINOk^' rw
BUILDING DIVISION PERMIT 'Co
NTRACT,OR INFORMATION ",:
au1LDING ADDRESS: SHEPHERD SERVICES PLUMBIN ER9TND03100038
OW NER'S NAME: 10121 IMPERIAL AVE PERMITISSUEDATE
NE` 4085597160 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: 'BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
!O0 LICENSED CONTRACTOR'S DECLARATION' ] b Description
I u G I hereby affirm that (3SCTI Thal I am licensed under previsions of Chapter 9(commencing p /
U wilh Scnion7IXX1 of Division3of die Business en Prufessiuns Code.md my lice..is 'p s
I, cls C,31i g
>�
in c I NEW GAS LINE
Date cralmnt INSTALL APPLIANCE-CONVERT EXISTING Q J
qq
ARCHITECTS DEC LAR oN IZ-J;Cf.o ELECTRICAL V
ig IundcraonJ my plain shalibcusdu pufd records
teu
'a(n Licensed Proressi...I
r OWNER-BUILDER DECLARATION
1 a I 1 hereby affirm that I am exempt from the Contractor's License Law for the
=0 0 following reason.(Section 7031.5,Basin.and Panfessime,Code:Any city in,many
Z m which requires a permit m comic act,alter,impmm,demolish,or repair any structure
iprior to its ismonce.also rcquira the applicant for such rermitto file a signed statement
F� that he is licensed moment to the provisiomr(the Cmtraeuxo License Law(Chapter 9 Sq.Ft. Floor Area Valuation
F (commencing with Section 7")of Division J of the Business and Professions Code)or
that he is exempt theim(mm and din how for the staged exemption.Any violation of $1000
Section 71131.5 by any applicant for a permit subjects the applicant to a civil penalty.( - APN Number Occupancy Type
nut more than Rve hundred doll...($500).
❑I,as,owner of the pmpeny,or my employees with wages as their nle compensation, 35710002 . 00
will do the work,and the swcwm is not intended or offend for sale(See.7014,Business
and Professions Code:The Convector's License few does not apply to an owner of Required Inspections
property who builds or improves f orcon,and who d.essuch work himselforthmugh his
own employers,prodded that such impmsemeno s.not Intended or offered for sal..If. 106 — SEWER & WATER
however,the building or improvement is sold within oro year of completion,the owner.
I builder will have do burden of proving thel he did not Wild or impmsc for purpose of 202 - UNDERFLOOR PLUMBING
El 1. 301 - ROUGH PLUMBING
I,ru owner of ct Se.,70..B exclusively convening with:)71becd contractorsContractor's
to
connrvct the project(Sec.7004,Business and Professions Ch0e0 The Comnnor's Li. 3O2 — TUB & OR SHOWER _
cense Law does not apply to an owner of property who wins or improves themon.and, 502 — FINAL PLUMBING ENERGY
who contracts for such projects with a eomnclons)licensed pursuant the Contractor'.
se,
Law. 506 - GAS TEST
❑I sexempt under Sec. .B&P C far this resson
507 - FINAL PLUMBING
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ore of the following declarations:
I have and will mainuia a Ccniftcme of Consent o self-insure for Worker's Compcm
mlion,u provided for by Section 37W or the lever Coda(or the performar.e of the
work!or which this permit is issued.
Cl
1 have and will maintain Worker's Compensation Insurance,ss required by section
J?IXI of the Tabor Calc,for the performance of the work for which this permit is Issued.
a Worker' Campenemaw Insurance cmar,and Policy n� �re: 2
Carrier. e I— Po o.: 5 l�
CERTIFICATE OF XEMOM WORKERS'
COMPENSATION INSURANCE
(This section recd not wchmpleted If the Perm,Is Iran.hundred callas(SIM)
or lac)
1 certify thin in the performence of the work for which this Permit is ismed.I shall not
employ any person in any manner so as or hecmme subject n the Workers'Compensation
Laws of California.Date
APPlfcant
NOTICE TO APPLICANT:IL offer making this Cenifcare of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or His perm it shall he deemed revoker.
.N. CONSTRUCTION LENDING AGENCY
1 hereby affirm that them its eomtructinn lending agency for the perfurmance of
34 > the work(ser which this permit is issued(Sec.3037,Civ.C.) '
4 in Lendces Name
=z Leaders Address
j 0 1 century Nat 1 have read this applicuion end tote that the above information is
, F coacm,l agree 10 comply with all city and county on inances and mule laws relating to
DU aboye.gcntionedlfamend hereby archon ureprtsenulivcs of this City 0enter upon the
�G ehnva(We)agree
to ertysave for inspection an Purpo.a.
y
(We)agree to cove,indemnify and kith harmless the City of against Said
id Ctagainst
fA liabilities,judgments,Shooing cxpen.srnIt, may in any wayaccme againstsold City
j in eonuyuenec of the granting of this permit.
APPLI ANT DE AN 5 AND WILL COMPLY Wto I&IT ALL NON-POINT Issued by: Date
OUR REG LATI S.
6 Re-roofs
Oreo pplicam/Canvaclor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wit the applicant orto,=wilding Occupant store or handle haluduus material
as deMcd by the Carnahan Municipal Code.Chapter 9.13,and the Health and Safety
nen,Scotian3ss33t.)? �_
ea All roofs shall be inspected prior to any roofing material being installed.
Y
Will the applicant oa future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants a defined by the Bay Arca Air Qual fly Management all new materials for inspection.
7d-
❑YesI have real Ne hanNrus materials requirements under Chapter 6.95 of the CalifonHealth&Safety Code,Sections 25N15,25533 and 25534.1 undersoM dW irom wilding
s notetammlyha a. n 1 it u my respousihilitymredly occupantofthe
ul me wh tithe t 'dill ccrfaCpi[i u ancy. Signature of Applicant Date
een author Jegcm /lJ (f/ Dan, All roof coverings to be Class "B" or better
CITY OF CUPERTINO 4 0 3 W O
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # OI Date:
Building Address: �\ ��
Owner's Name: I Phone#:
C ntractor: Phone: License#:
s �Pd 3
Contact. Phone: Cupertino Business License#:
Cv
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description: r
Kvo 4(1,0 �10J— \YL I _ r4- E?x,4\ 4c1
Reside al Commer is ❑
Cost of Project:
Qty. if
A li e Fee ID Fee Description Fee Group
PPERMTTFEE Plumbin.g 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
23377.
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