06080262 CITY OF CUPERTINO 0...........
BUILDING DIVISION PERMIT JZONTRACTORINk'UR�MA'CIOHN
A £?
BUILDING ADDRESS: ABLE SEPTIC PERMIT No.O 6080262
22100
OWNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO 520 REED ST. og /ii /2nnr
14 ONE:
SANITARY N0, CONTROL NO.
(408) 377-9990
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EI.ECf PLUMB MECH
0
Oj LICENSED CONTRACTOR'S DECLARATION - Job Description
thereby all that 1 am licensed under provision of Chapter 9(commencing
�<W with Section 7")of Division 7 of the Business and Pro v CON,Ud my license is
infull fo=and effea � 7d(7 REPLACE SEWER LINE
i�= Liam Class��omiu
i n K Lie. n ,ceryl Conuacor
ARCHITECTS he
DELLA re ION
Kbie
Ml< 1 undcruanJ my plain CHIT he aced u public DECLARATION
U
.pr' Licensed Professional
3 OWNER-BUILDER mDECLARATION l_
C c I hereby mano .(Tiro I am exempt from Nc C scions Co :My c Law for the 4 p
-O o following mason. ct(Section 705 L5.Ruiner.and Professions Calc:Any city or county 6
with its ism n permit re cnnawct alisic improve.h permdern-lit t or e:a sig any stremum 15 O O O
prior to its i Bernard
p also require tHvision of for such permit m Ole a signed statement
o That(commencing
with
Purmann loth))of Difions of NC Canuinessadd Pmelaw(C od)))or Sq. F[. Floor Area �� Valuation
tham a is exe with Secuon a and of Division 3 of the Business and Professions Code)of
a�$
that he u exempt Nemfrom and tha bash for the alleged esrmpum.Any violation of
Section 7031.5 by any applicant for a permit mbjena the applicant o a civil penally ofer OType
acs more Nan Bve hundred dollars Occupancy Y YP
❑I.uowma of Ne propmsy,or mY mvployaa with wagea uNu'v sole eompenssdon,
will dothewon.Code:
swmureewts Liciadoron,doss Out a(Sec.o ax,Bmerof
and Professions Cade:me msthe on,Uceve Law dna Out apply lf rt ower is Required Inspections
man
property who es.ppr arimpmea Merton,end who arm net in work himself edNmugh his
own)) .th Wilding
ding or i Natwchimpsmid whom
arm net ear ofcided aroftered for osale.IL
however.the Wilding ar improvement u cold within orc Wild of completion.Ne uwrcr-
builder will haw Ne burden of proving that he did not Wild or impros<for pugou of
sale.).
❑1,as owner of Ne property am exclusively contracting with licensed contractors to
covwct the proXer(Sec.7014,Buinrss and Paressimu Cade:)non Coeoacwts W-
cove Law don on,apply to an owner of pmpeny won Wild.or imine.daemon,and.
who contracts for such projects with a coneactor(s)licensed pursuant to the Contracro's
License law.
❑lamaempoundu See .B&PCfor Nismamn
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I ham and will maintain aCeruGesre of Covent to aelf-insure for Wodus's Compen-
smian.as provided for by Section 5700 of the labor Calc,for the prOr mance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compewtion Insurance,as required by Section
5700 of the labor Code,for Ne performance of Ne work far which this permit is issued. '
My Worker's Compyeva4 lnsurane�j a,and Policy number
Cartier.!6L P. �yNC Palicy Na.: K
CERTIFlGTE OF EXEMMON FROM ERS'
COMPENSATION INSURANCE -
(This mnloo need not be completed if Ne permit Is Toon hundred dollars($IM)
nr leu)
I ceru)l Nat in NO perfumumeti of the work for which this Permit is issued,1 annul not
employ mypcmon in my mmmrm az to Wcomc subject to NC Workers Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this CcoiGeau of Exemption,you should
become subjem to the Worm's Compensation provisions of dae Lanor Code,you most
.J O forthwith comply with such provisions w this permit mall W deemed revoked.
'z c CONSTRUCTION LENDING AGENCY
[—� Thereby affmt Nas Neu is a rovtructinn lending agency for the praormancc or
the work for which this permit Is issued(Sec.3077,Civ.C.)
14p Lender's Name
0.
7 z LcnN/s Address
U0 I certify Nn 1 have read this application and sum Nn 1W aW ve information is
U. F torten.I agree to comply with all city and county ordinances and sure laws relating to
0U building cunsuumion,and hereby authorise representmiva or Nis city to cnmr upon the
r 0. aWvctmcnuuncdpmperty for i expnies purposes
(We)agree to um,indemnify and keep harmless Ne City of Cupcmirm against
,Fw z liabilities,&Pp
rd,
and expenses which may in any way accrue againnsvd City
U z e of Ne granting of A permit.
^ U TIONS.NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date MONS.
I"C7G Re-roofs
Signa,. ofm ApplicasUConuacor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or form Wilding aeupantsmre or handle imitations mamHal
az defitud by the Cupertino Municipal Code,Chapter 9.12. ad Ne Heath and Safety
Code.Section 25532(x)?
Y. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forum Wilding=upon,um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Omit havardnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Disria? ////������—�
❑Yes •"TCI Na
Ih dm naaard".a materials mc.ircrocnu uiderChapW6.95 of Nc Caliror
nia Heal &S Code.Sec. 25505.25533 and 25534.l understand un if Ne Wilding
does not upend have atep.6L Nat itis my rupmnibility to ondry 1M a<up.,or Ne
not to wide re met pdartoiim..ofaC'mricauoforcuparxi. Signature of Applicant Date
Owner or tonnotOddagent Dare All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
I ,/ Cupertino CA 95014
-,.
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
*UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
21 pp Sle .oma CY-k 060s-0-z-c-'- Z
OWNER'S NAME: o(' PHONE #
GENERAL CONTRACTOR: A6 FAX#
I am not using any subcontractors:Z - erc.3) 'd lV
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
•
Owner/Contractor Signature Date
CITY OF CUPERTINO aoanw-
�' REPIPE/SEWERS/MAIN SERVICE
UPERTINO PERMIT APPLICATION FORM
APN # 35-1-I r,y Date: p 3 1—G /
Building Address: `�J I O ro
�� I d0 �T,eJen Cr� l�
Owner's Name: Phone�##:
Ct 1 A dF CLIPCI- Rd ik— 326
Contractor: Phone: 3 7� _ I�Q� License#-
)} le v�d ei �d ( I -1 �l S
Contact: Phone: Cupertino Business License#:
Do,L/ y �� - 7i93
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: n
f Iz PICIC eS Nu e/ i n c—
Residential ❑ Commercial
Cost of Project:
l � ood
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
•