03100063 'r CITY OF CUPERTINO �,
BUILDING DIVISION PIrRMITCONTRA -TORINI+ORMATION
„ Bu1LDwc ADDRESS: CUPERTINO PLUMBING PERMIT"003100063
9,21;14 VQq.0 AV
OWNER'S NAME: 10297 S DE ANZA BLV PERMUISSUEDATE
BUENO RONALD 003
ONE: (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHI'IECr/ENGINEER: BUILDING PERMIT POPO
BLDG ELECT PLUMB MECH
0 L 0 0
10, LICENSED CONTRACTOR'S DECLARATION
w 1 hereby alarm that I am licensed under previsions of Chapter 9(commencing Job DescriptioT�
with Scaion 7000),r Division 3 onc�Bosineac and Profession.,Cade,and my license is 1N��
air
It
-z9u REPIPE/WATER MAIN/WATER HEATER
q i Licenm Cie9aa 'ct 4 Lic.N
Dale M^! Contact.,
£�£ ARCHITECT'SDECLARATI N JAN g 2004
1 C 1 understandhe my plans shall used as public records
]yU
Licensed Pmfcssinnel UU'
OWNER BUILDER mDECLARATION I D'ivG
<P 1 hereby affirm on 1 em exempt from He Contractor's Licenu Law for the (�
00 following lesson.(Seaton 703 1.5 Businer,andmpr ve de na Code:Any tiny or county
<m which myuiresne,alio re ennswel,,torn improve,h Perlia mrd a repair any svoeum
prion.its Issuance,pursuant
requires the theapplicant
sor for sucContrarmitmicense aw(Chmmenr
a
that remaining
n7 00dofDi.viormnrmcConwnessanicenselzw(C Code)
Sq.Ft. Floor Area Valuation
Z (commencing with Senion]of10)nf Divisiun3nf the Business and Professions Cn on or
Nat he is exempt therefrom and one basis for the alleged exemption.Any violation of 34229018 . 00
Section ID3LShy any
iCLntt for
&Penimiwbjccts the applicant o acivil Penalty Of
not moe than Eve handled
dollars APN Number QCCu ane Type
.__
❑I,az owner of the properly,or my employees with wages as their sole compensation,
will do the work.and the inclum is not intended or offered for sale(Sm.]M4,Business —
and Profusions Code:The Conuaccor's License Law does nut apply to an owner of pfgrirS
property,who bailor oeimprowat menton,and whndoeaxum walk himth
self., rough his 202 — UNDER UMtS1NG
own employees,prodded mat such improvements are,not intended or offered for sale.If. 301 — ROUGH PLUMBING
however,me building or improvement is sold within one year of completion,the owner.
builder will have the burden.(proving mat he did not build or improve for puryose of 302 — TUB & OR SHOWER
ale')' 502 - FINAL PLUMBING ENERGY
❑1,as owner of the property,am exclusively contracting wit licensed convectors to 506 - GAS TEST
consumer the project(Sec.]044,Business and Professions Code:)The Contractor's Li
cense Law does not apply to an owner of progeny who builds or improver Ihem.n,and 507 — FINAL PLUMBING
who contracts for such projects with a convector(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B k P C fon lis mann
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby 4MM under penalty of pe jury one of the following declarations:
1 have and will maintain a Certificate of Consent to salGinsum for Worker's Comped.
sation,as provided for by Section 3100 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Campensanion Insurance,as required by Section
3700 of the Labor Code,for he performance of the work for which this pnmis is Issued.
My Workers Complication Insurance carrier and Policy number art:
Came,..�d^�'-T4a�p(� Policy No.: _
CERTIFICATEOF EXEMPTION FROM 70 K
COMPENSATION INSURANCE
This section need not be completed If the permit is rnrmm hundred dollsm(SIM)
,it leen.)
1 eenify that in the Performance of the work for which this permit l issued,1 shell nut
employ any Nixon in any manner ser a to become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should _
become subject no one Worker's Compensation previsions of the Labor Code,you must
Oforthwith comply with such provisions or this permitslall be deemed rooked.
z CONSTRUCTION LENDING AGENCY
1 hereby affirm than there is a consvuctinn lending agency Ire the performance of
14 > the work fur which this permit is issued(Sce,3097,Civ.C.)
.y Q Leader's Nam.
z Lender's Add. .
J C 1 eenify that I have read this application sad slam that the above information is
colscct.1 agree to comply with all city and county ordinances and sate laws relating m �-
building canw
sction,and hereby Wounixe representatives of his city to enter upon the
GU ehove-mentioned progeny for ilupccuon purposes.
-. (We)agree to save,indemnify and kccp hannlea the Ci ly of Cupenino against
N
liabilities.judgments.count and a(this es which may in any way accmc against said City
J 7 A PLICANT orthe granting of this permit
r^^
APPLICANT yrogg_ ('tpITH ALL NON-POINT Issued by: Date
SOURCE REG S � t
�0 '�- a Re-roofs .
]Ignat oro mei'^�
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant LOM or handle haysrduus mammal
az derided by he Cupertino Mumci ode.Chapter 9.Iz.and me Health end Safety
ode.Senion zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ho'raNnus oil comominants not ucl=d by the Bay Arca Air Quality Management all new materials for inspection.
iuricn?
❑Yes Nu _
Ihavereadthch.. in malarial q.tionacrolocknCh.pler 6.95 of the Califor,
ria Hcalthd<Safct Codc 5 71553 tl]3534.lu d than ifthc Wilding
oras oatcur calla u 4" re am nou ll the recum paof he
mvaica s yf' u cinaamyra .iy.� S' ure of Applicant Date
_SH / /�'
wnm.r a sized ,Ft— � All roof coverings to be Class "B"or better
CITY OF CUPERTINO 3 ( �
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# /, Date: p
Building Ad ess: C/
Vcl-s 5
Owner's N e: Phone#:
3153- 94130
Con ractor: Phone: License#:
61!3aX53-c� ig C�a4/7o,5
Contact: I Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: CG ,¢r Po1 ��(y✓ b1 ��J. Fyr
Residential ommerc al
Cost of Proje
Js
OU
Qty. if
Appli A Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
b 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
M2�67L
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