03070228 CITY OF CUPEW11NO
Huu.D1Nc mvlslon PERMIT ��CON,TRACTOR INFORMATIQN• .
r,S ��s ps
Bu1LDINGADDRESS: BAY AREA REPIPES PERMIT NG03 O 7 O 228
a OWNER'S
NAME: 1861 ORANGE GROVE DR PERMrrlssueDATe
GRAVENHORST HENRYD
NE: (408) 371-5763 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUOMB MEQCH
?00 LICENSED CONTRACTOR'S DECLARATION
wp 1 hcrcby affirm that 1 am Rwn'ca ander p,ovislnn'nrchapt,r 9 anmman=Wg Job Description
�ZW with Sectio ]IAAE of Division 3 Ne loco and Profcsainn'Code. tlmyliccnu is
<< in fulf and eft
>'q� Lieea sss �"'_3�o Lux., @193 REPIPE/ NEW WATER SERVICE/WATER HEATER
II-- Dam C.".W
fy ARQry1TECTsormpu.ARATION
22 �n o /oY[6�)tI ne\mN➢(a:pp ARATI ma
>au
e0� Lmensed snma�--'
j OWNER-BUILDER DECLARATION
V F I hereby affirm that I em exempt from the Contractors License Law for the
LLL O O following reason.(Section 7031.5.Business and Professions Code:Any city or county
<$°i6
� which requires a permit to construct,alter,improve,demolish,nr repair any structure
prior 1. im.mMe,alsumquims the applicamfee such permit to file a signedaummcm
that he is licenud pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
2 (commencing with Section]000)of Division]of the Business and Professions Code)or
OR Nat he is exempt tWmfrum and the basis for the alleged exemption.Any violation of 36914006 . 00
Section 7031,5 by any applicant for a peomiuubjem the applicant to a civil penally of ppN Number Occupancy
not more Nane an Eve hundred dollars(S500). p . Y Type
❑ 1,As.wner of thep.parry.M my employers with wagesu"eir,olecampenatlon,
will do to work,end the swmum is not intended.,.Hated for sale(See.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of 5 02 - FINAL cRGY
progeny who builds or improves thereon,and whodoes such work himself or through his
own employcu,provided thaswh improvements are not intended oroRered for me.¢ 507 — FINAL PLUMBING
however.Ne building or improvement is sold within one year of completion.Ne owner.
builder will have the burden of proving Nat W did not build at improve for purpose of
ulcJ.
❑1,as owner of the property,am exclusively contracting with licensed cornactors to
Concoct the project(Sec.7044,Business and Profusions Cade:)The CmrrAcwr's Li.
cense Law dors not apply to an owner of property who Wilds or impraw thereon,and t�
who contracts for such projects with a contractor(')licensed pursuant to the Contractor's
License AUG 1 4 2003
C-1exe 1 m exempt antler Sec. B k P C for aso
this ren
Owner - Date
WORKER'S COMPENSATION UECLARATION BUILDING
1 humbly affirm under penalty of perjury one of the following declarations:
73011
have and will maintain•Ccnificne of Consent to ulfinaum for Workers Copper.
n,a provided for by Section J]W of the Labor Code,for the performance of the
for which this permit is issued,
have and will meinuin Worker''Compensation Insurance,a rtyuircd by Section
of Ne lsWr Code.far the rformmce of Ne woh forwhichNis permitisicedWorYp Crynpetion In now aortia,andPlicy nu bcraLer "IfN•!It o --Pol_tfvA?la.:Z290L1
C RTIFIC—T ATE— OF EXE h P1ON FROM WORKERS'
COMPENSATION INSURANCE
(This auction need not W completed lite,Permit is for one hundred dollars(SIIXp
sur leu.)
I ec tify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner an u in Wcome subject to the Workeri Compensation
Laws of California.Date
Applicant -
NOTICE TO APPLICANT:If,.flat meting Nis C.Mfimim of Exemption,you should
become subject to the Worker's Compensation previsions of But"hot Coat,you most
�z rortlovi th comply with such provisions At this Permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby afRo othat"ere ire construction lending agency for the perfurmance of
Yi ti Ne work fur which this permit is issued(See.3097,Co.C.)
'Z) Q Lender's Name
z Lenders Address
:J Q I coolly Nat 1 have read this application and sum that Nc shave infonnatiun is
.4 E' correct.)agree to comply with all city and county ordinances and state laws relating to
0U building ConmuNon,and hereby aurhoned representatives of this city to enter upon the
G shove-mominned property for inspection purposes.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilities.judgments,coats.. upcstsea which may to any way accrue against acid City
Jz to consequence of the grant .(this permit.
APPLICA DER OS AND WILL COMPLY WITH A L NON-POINT Issued by: Dat
S L
--- L e-roofs
Signal cof ApplicanUContncmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne Applicant m futoro Wilding occupant start M W ndle havudou.material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
a1c.5ecti us No
25372(,)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or fuwre building occupant tau cyuipment ordcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
h haesrdnus air conmminanu u defined by Ne Bay Area Air Quality Management all new materials for inspection.
is Viet]
❑Yu �No
I have read Nc haraNnus materials requircmcnu under Chapter 695 orme Califnry
nix HcalNASafcty CK
25X15,25577 anJ 255Jb.luwcmtand Nutifthc Wilding
does nm eNat it is my responsitelity to wo
mqui PH.,toissuenct.r.Cooliesnature of Applicant Date
wnc Iaor ... - All roof coverings to be Class "B" or better
CITY OF CUPERTINO v 3
REPIPE/SEWERS/MAIN SERVICE .
CUPEkTINO PERMIT APPLICATION FORM
APN# r Date:
7� C�
Building Address i
\
Owner's Name: K� Phone#:Z sem- 9Zd
Contr c r: hone- License#:
"37t— G
Contact: Phone: Cupertino Business License#:
AC �� whut5o �' 3a► -�`�`��
2-37-73
Building Permit Info:
B1 Elect ❑ Plum
Job Description: L-46
Residential F /ComAercial ❑ L�'
Cost of Project:
•
Qty. if
ApplicaFee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
B LIC Business License II G
W
377 ��