04030244 CITY OF CUPERTINO F '^' 7 '2,7 ` ,�' 77, " ` ,
BUILDING DIVISION PERMIT ;,kCO�TRACTOR�INF,ORMATIQN ,'
BUILDING ADDRESS: BELL PLUMBING INC PFRMITNOO4O3O244 -
OWNER'S NAME: PERMIT ISUEDATE
JIMMY
ONE: SANITARY 14V QRAOL NO.
ARCHITEC 7TENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
o p LICENSED CONTRACTOR'S DECLARATION
I hereby of on Net 1 Am:iawcd under provisions of Chapter 9(commencing Job Des g01011—
_ei MdhSccn7fKK))afDivisionSoftheBud PwfeasionsCode.andmylicenwb ��
^❑A da
g 2 License hurmfu rtaC�j6 SZ'r°7� 6 PROPERTY LINE C/O
j Lia.
t Dam Con or L .4
RCHTIECTSPRHARATION MAR 3 12004
y ndeRuml my plans sluAllitusedlerphikoseranda �C'Ov'ru ✓���
3
a Lkcnsed Profeulonal
='O OWNER-BUILDER DECLARATION 13UILDING
.� I hereby affon that I am exempt from the Convector's License law for He
D O fallowing reason(Section 703 1.5,Business and Professions Cade:Any city m aunty
$ which requires A Permit to construct.elan.impmro,damolinh,fir repard,any a.[..
p,ZL^ prior to its issuance.Also requires the applicant for such Permit to fila a signed statement 472
€< thathcislicamcdpumnnalothaprorishnsaflheConuacmr'sUeemseLaw(Clutier9 Sq. Ft. Floor Area Valuat on
$ (cromoncdngwithSeed.70a0)of DMsiun3of Ne Businessand Pmfcsions Cdle)m
Out be H exempt Territorial
and the basis for the alleged exemption.Any vlolatton of .�y-�s�NR,....l,
Section 7071.3 by any applicant fw•permit subjects the applicant I.A6 dismally of 3 !'99eJ G4��gro0 Occupancy e
not more than five hundred dollars(M], p yTyp
L,asowxr of the propmy,ormy cmpioyaa with wagmasthelr sole ampenas0on,
will do the work.and the saadurt is not Intended oroncred far Set.(Sec.7011,Business
EPrefasslons Code:The Comore nes License Law dors not apply w an owner of Required Inspections
property who builds or im pmvrs ft...and who does each work himself m though his
employees,pmvided mat such improvements are not intended or offered for Asia,IL
A..the building or improvement is sold within one year of ca.,team,On owter-
builder will have she burden of proving that M did not build or improwe for purpose of
Asia.).
❑1,as owner of the property,.m exdmtaly comnsi ns Co :iansed fit oacton to
cans,La the es not apply
to an owlbuner
of,and Professions Cade)The Crovactora V-
arise law does not apply je an owner of property who betide ortthe own Centra,and
whonse acca for such Projects with a conuector(s)licensed pursuant am to Contractor's
soar
L La..
❑Lem exempt undo Sec. .B&P C for this mown
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aBimt under penalty of perjury one of tie following declinations: '
1 hew and will maintain a Certificate of Consent to se:(-inure for WorkersCompen-
"nom,As provided for by Section 77M of the Labor Code,for the performance of the
work for which this Permitis issued.
C i have And will Aimam Wmicar',Compensation Inwrutce,as mquined by Section
3700 of the Leber Crude.In Ce performwceof for which this permit is Cued.
M W,kers Cnm asetian 1. nce cenicnnd c number Am:
Y Y J
e c :S 4 �G U/y�}pg try No.: 7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed notbocompleted ifthe rvor ,le fmamthundred dollars(SIM)
or It.)
1 certify Cat in Ne performance of Ce work for which this Permit in issued,I shall not
employ any person In any manner to an to become subject to the Workers'Compcns.dort
law.of Ca f..I..Data
Applicant
NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,You should
become subject to the Worker's Compensation provisions of Lha labor Code,you must
.JO forthwith comply with such previsions or this Permit shall M deemed Acwked.
z .~N., CONSTRUCTION LENDING AGENCY
P I hereby allirm that them is•eonstroctsm lending quorry for Ce perform.of
a� the work for which Ods permit is issued(Sec.3097,Civ.C.)
0.0 Lender's Namc
w1- Z I.A.AWs Address
U0 I ar ify that 1 hoe read this application AM sista that the above Information I-
Is.H correct,1 egme to comply with ell city and county ordinances,and sum laws Minting to
0U building tousbactirn,and hereby autharim representatives of this city to Amer upnn the
U aMve-mentioned property for Inspection purposes
Ft+'4 (We)agree to sew:,indemnify and keep harpleu the city of Cupertino against
to :iabilitim.Judgments,costa nd expense which may in any wayacertte against avidCity
I'j 7 in consequcn��'ILL
it.
4PPLCAM COh]PLY WITH ALL NON-POINT Issued by: Date.4�JJ'/ _
Re-roofs
Signatort o(ApiflicarnfiCarbactor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ca applicam or future building occupant store arhandle hazardous manorial
as defined by IM Cupertino Municipal Code,Chapter 9.U,And the Health and Safety
Cade,section 15531(.)+ L' All roofs shall be inspected prior to any roofing material being installed.
❑Yes gyne
future building wcupont use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or
100r,'o,
mit havardau.air contaminants an defined by the Bay Area Air Quality Management all new materials for inspection.
District? J
DYas ONu
I haws read drt hvardoua materials rcquimmcnts undo r Chapter Q95 of the Cali for-
maHAabh&Safely Cabo,Secuwu 303.2553 25531.I undeoutd Outlie Wilding
does caw curmmtiy have e e responsibility se notify the oaupanu of Oe
quirementswhichmu nm u.naof. mne.mofaaPancy. IgnatureofApplicant Date
� -3- 0 All roof coverings to be Class"B"or better
a mired agent Dom
Community Development
10300 Torre Avenue
alor-
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRE : QZl RMIT#
OWNER'S NAM PHO Zj 3 - 6
GENERAL CONTRACTOR: -« ,Ta FAX #
I am not using any subcontractors:
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
,>e �/
0 Plumbing /fEcc Lo.•»Ci� l �° Q Z 7� D c'3�
Roofing
Septic Tank
Sheet Metal
Sheet Rock
AK Tile
'Z r/Contractor Signature l/ Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE o*a3 0,/�
CUPEkTINO PERMIT APPLICATION FORM
APN # �r 33 Date: ' O
Building Address:/ to//
lJ ^ v
Owner's Name: !D /I Phone#:
.T T, - �53- 9658
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ umb
Job Descri 'on:
Resid6ntia Commercial ❑
Cost of P oject:
Qty. if
A -We Fee ID Fee Description Fee Group
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