04020156CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
9dCONTRACTQR INFoORMATIQN;
BU ILDING ADDRESS:
070n All
PERMIT NO.
04020156
OWNER'S NAME:
PERMIT ISSUE DATE
MILLS
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT?ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
et I Am licensed under provision of Chapter 9 (commencing
1 Mreby afflrm Nns
- P
with Section 7") ofDivisi Jar the Buitwm and Profnsoms Code. and my license is
in mu roue eerr
`��
WATER LINE REPLACEMENT
Lieenae el Lth.«�
c°^t"
ARCHRECTS DE ATION
CONTRACTOR: READY ROOTER PLL? 4�eLNCd A�O�. �D
I Automated my Plan shall he ussd u public rtrnrda �� d
■���ad��41�
MAR 1 2004
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm hat 1 emmexempt from the Contraarofa License Law for the
following moon. (Sado^ 70 31.5. Business end Code: Any city ver county
vex. de of sig any stunurt
which requires • re construct, else improve, demmMh, m
soon c a ettment
atso require the o for such Permit to file • Law
Prior m its issuance.sed
Sq. FL Floor Area
pr
50
(Lost comma ccenxdPurmannmNcofProvisionsoftheContruessandenulsw(Chapte9
Section 7000) ofDivision Cadn or
or theBusinessexemption.
f0
Any
Net he d eaempl thertfram and then bud for 0m alleged eaemptlon. Any Wobllon of
that he exempt
APN Number
ane
Occupancy e
�'P
Section 7031.5 by any applicant for a Permit subjects qtr applicant to a civil Penalty of
out roam Nan five huntlmd dollars (M), - -
P Y
32649012.00
❑I,asawnrufthe propcnY.mmY wPloyce with Aguas Nev sole rnmpenadm,
.
will do the wort, and the structure is not Intended An offered for go (Sec. 7044, Business
Required Inspections
and Profetdoae Code: The Contractor's License Law den tan apply N an owner of
property who builds ver improve thereon, and who does a tach work himsel f or through his
own employee, provided Net such improvements are not intended oroRared for We. If,
however, Ne building or improvement is sold within one year of completion. Ne.,.
builder Anil law the bound. of pmviog w, k did not Mid or improve for purpose of
sale.).
❑ 1, As Owner of the property, am exclusively contracting with licensed contractors in
construct the prolix, (Sec, 9014, Business and Professions Cade:) The Contractor's Li.
cane Law does not apply N an matter of property who builds or Improves daemon. ad.
who contracts for such projects with A cors rsstom(s) licensed pursuant to dw Contractor's
License Law.
I exon temp, under Sec. ,B&PC far this reason
Owner Dom
WORKER'S COMPENSATION DECLARATION
I hambY e111. under penally of pejury oro of the following deedrations:
1 have and will maintain a Certificate of Cotten, in stir-iasure for Workers Camper -
Or. u provided fm by Section 3/00 of the Labor Code, for the perfo..... f the
rk for which this permit is Issued.
'
I have and Aill maintain Worker's Compmarhon Inurance, u requited by Section
°rNe labor Cotle. for lha performamx of the work (mwhich Nis permit is Wood.
y Worer's Cooper aatioe Insurance caniar end Policy number em:rtier.
Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this scmim need no, he completed if the Permit is foram hundred dollars (SIM)
ter let.)
1 unify terth rformanee of the work for which this permit H issued, I shall not
employ eny pc any mann s tub ubjul to the Workers' Compensation
Law o(Celi is�Daem
Applienl .
N ICK APPLICANT: 19. g This CertiBem of Exemption. you Nauta
d
to Worker's r'e Com provision of the Code, you mut
Compensation
rSubject
comp it s Of thin mondLather
f rnmPIY with such previsions ver this Permit shall M deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby afr m that there its eonmmEon lending gency for the performance of
the, .,it for which olds Permit I, issued (Sea 5099. Civ. C.)
_
Undoes Name
Lender's Addles
1 certify that I have read this Application and emu that the above information is
correct. I agree t0 comply with all city std county Ordinances and able law relating to
building construction, and hereby a^N°rim representatives arthis city to enter upon the
shove-mcnti°ntA Property (m inspection Purposes.
(We) agree in save, Indemnify and keep bamtleY the City of Cupertino against
Ii.bllitmAjadgme.tco.sesan CFpClrae]WhllCh may,. any way .,..against said City
in co q ncc of the grand of this pemie
AP ICA UNRS D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S U E E U S.
Re -roofs
d
_
pph for
HAZARDOUS MATERIALS DISCLOS E Data
Type of Roof
Will the &pollen, or future building occupant atom or handl. hevudous omenal
'
As dcancd by Ne Cupertino Municipal Code. Chapin, 9.1; and the Health and Safety
cede. Section Vi5724)?
All roofs shall be inspected prior to any roofing material being installed.
[I Yes O
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant esu equipment or devices which
mit hauardous air contaminants As defined by the Bay Arca Air Quality Management
all new materials for inspection.
District? �/
Clyne fern-
t
Ih most ehvmdmem als mquimmcntsundcr Chapterfi.95ofdmCalifor-
At.Heal Safety we,Sectio 5, ad255M.1undcomtthaifthebuilding
docs n currently Ave a nae u m sponsihility m nmdfy the occupant of the
mm arm' mecoface'frxaa 0ce.poncy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
A, authorisedagcm Dat
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS
o
PERMIT`
O o2-0 /S
OWNER'SN EI
PHOTIE # Z
GENERAL CONTRACTO
FAX #
•
I am not using any subcontrac = --_ Z ZS Date
Signature te
Please check a licable subcoritractors and com Tete the following' ormation:
10/28/03
Date
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
She ock
e
10/28/03
Date
•
•
•
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
0 C.,[ O,�) 0 (-r�
APN # 32-�o g I Q 12�
Plumbing Permit Issuance
Datey�/Z� Q
G
Building Address: f4
Re i e of Fixtures
PLUMBING
Owner's Name:
Permit Fees
Phone #:
. LL
e(31 S� Cp
PLUMBING
ntractor:Phone:
C°o
License #-
�l9(oz
oo
BPSEWER
Sewers
Co act:
Phone
Cupertino Business License #:
PLUMBING
BUSLIC
Business License
Building Permit Info:
Bldg ❑ Elect ❑
Plumb
Job Description:
(mac duke
(Zce MC
Residential Commercial ❑
Cost of Prot ct C�-,
Qt}y'
AWH'ciable Fee ID
Fee Descrintion
Fee Gmun
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Permit Fees
BUILDING
BPFIXTURE
—Bldg.
Pbl . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING
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