04120107 CITY OF CUPERTINO -
BmLolNc-mvlsloN'._. PERMIT
UILOING ADDRESS: CUPERTINO PLUMBING PERM11N'b4120107
1002 WESTLYNN WY
HER'S NAME; PERMITISSUBDATB -
.GUERRY JOHN L AND ARLYCE A 10297 S DE ANZA BLV 12/15/2004
ONE: SANITARY NO. - CONTROL NO. '
(408) 253-0618
'ARCHITECryENGINEER •'.. - ' f '... - - .
BUILDING PERMIT INFO
OELECT PLUMB MITCH l� _
LICENSED CONTRACTOR'S DECLARATION - .. Job Description
1 Itereby affirm that 1.m licensed under PmWNmu of Chapter 9(commencing. - -'
with Section 7000)of Division 3 ofdm Businessland pro(ealom Cokand my license is
mfenmroe anaenec e _oil_ �. COPPER REPIPE
qq gq License CI - Lk:I _'�j=�
n Dam v Contractor
ARCNITECrS DECLARATION 2
�i 1 plans CH IEseed apublic CLARremrN
3 -, -
- 5 cad Lle sed a nal .
Oat I not UILDER DECLARATION
a E I make.(Ones that 1 1. eanmpl from the Conuncum License Low for the -'
O e following mato..Permit
t 703 L5,Business and Improve.
Canadian,
Code:My city m manly /
a$
which mqulmt n permit re cores the alter,Improve,dommW,m e repair g any Moleculstatement •-
.:
poor miu issuance.also mqulma the applicant faranch Permitm0le aalgned aulemem '
�< th.thoisllcom dpurmantlo theprovidomoftho Conmwe$ULT= aw(ChaPwr9 Sq.Ft.Floor Area /Val u OIT
(commemingwidr Sredon7000)af Divimim3oflhe Butyn mdPmfeniam Cac)or
mal he k exempt dterefmm and the link for the alleged eempim.My violation of
-
Section 7031.5 by say applicant pass permit subjecu the applicant u a Civil Penalty of
net more than ft.hundred dollars(S500). e C Cy pC
` ❑I.m manor of the property.or my employees with wage u their sale Compensation, _.
will do the work.and the structure k not Intended or offered parishes(Sm.7044,Business - Required Ins ections �-
_
and Profession,Code:TIC CommcM LI¢na Law dw set apply m an awrc of 11 p
progeny who ddldaarimptoeadermn.andwhadonaucA work himself orlluoughh4 - — ' '
howeer.the
eesilding orIthroveentis std wBarcmyearndedmoRak.
however,inhe"dingorden of ementksalde did act year or Improve
the owner-
builder win Mva tiro burden of proving Net m did not Wild u ImProw(o purpose of .. . . .- -
' Elea)..
1.u owner of me property.am exclusively mnucdng with licensed mngamon m
construct the pmjea(See.7044.Business and Professional Code:)The Cortisone,U. -
.. come Low does not apply m an awmer of property who builds or improves thereon.and. '• ..
who contracts for such pimpom with a contractor(,)Iimmed pursuant m the Conuactor'a - - -
01sur ccreptunder Sec - .Bin PC far Link roam r--- --'— '
Dem
WORKERS COMPENSATION DECLARATION.a.. -- -_ _ " ••"•^'' °`• -'"— -
1 mmby alarm uM r penally of perjury om of tie fallowing declaralam:, _
IMro.nd will mainulnaCvdficateof Canatioself-loom for wortrhCampen- -�
wo'f u pmviMA fpe mi Satire 3]00 of the labor Code,for Ne pcdannance mf the '
wa for which this permit Is issued. - -
1 have and will maintain Workces Compensation Imuran,a required by Section _ ... ....,
3700afthe labor Cadc,for the perfarmanmafthe work forwhich this permits tuned. _ — - ----- -
My Warkees 1Care oration Imuran carr�'er and Paliry number are:
Carder._/fi
Policy No.:
�7 Le 411
CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPENSATION INSURANCE
- Crhk section and not he completed lfthe permit Is foram hundred della.(SIM)
or less.)
1 certify thin In Lou performance of the welt for which this permit is Wasid,I shall not •- - --
employmypersonin.ny manner=as in become subject to be Wmken'CompemNon .+ -
LawaofCaB(amla.Dete
Applicant -
NOTICE TO APPLICANT.If,after making this Certificate of Escounion.you should -
become subject m the Worker',Compensation famia lens of the labor Code,you mus _�--
.,O foMwid,comply with such previsions or this Permit shall he accord!ravelled.
CONSTRUCTION LENDING97,Ca. .)
(~ NCY
Ihereby affirm that dere Is a mm0ucden lending agency for the perfcrmance of
a.,>-, the work for which that permit u iuued(Ss..]097,Civ.C.)
W Q
Le does Name
M z LeMeYa Add.
U Q 1 m tify that 1 have mad this application and sum Nn the.have InformNon is -
gy;'! coama I ague to comply wish all city and county ordinance and sum laws relating m
0 arJ building contraction.and hereby mthodm representatives of this city or enter upon me
W ahovmmantioned property for impeedon Purposes.
G (We)agrte m n indemnify and keep haamlet tie City a(Cupcnino ageiml
IIBWINe,judgm ,coN despen i which may in any my erne agalnnaud City
V F77 In eomequen fNa ti of thio Permll. -
APPLIC Df AND WILL COMPLY WITH ALL NON-POINT Issued by: Ddte
Mu
Re-roofs
gmum_ HAZARDOUS MATERIALS DISCLOSURE minictor Data Type of Roof
Il site applicant or future building nupant Nam orhandle broadloom material
as defined by the Cupenlno Municipal Cade,Chapter 9.13,and de Health and Safely
Cade,SminkOYU 25531(a)T tr All roofs shall be inspected prior to any roofing material being installed.
❑Yes rose.
Will the applican or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree do remove
Inialical"
ork hnudous air comenume ,u defined by th Bay Are.Air Quality Management all new materials for inspection.
Nricl7
Yes u
I have mW the inn rdan materials mqulrmenu underChapterh.95ofuc Cantor.
Sa(o1 ,So dom75505,35533and25534.1 undasund thin fdc building
on notGhvu e te an4 Lha it u my mepomibility m nmify the nupant of ateequirtmen 'ormiuusnof.Cenifica ar Ocmpamy. Signature of Applicant Date
owner ar vex gent 1 � All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�PERTINO
Building De artment
JOB ADDRESS: /46Z kV,/ -s-M �jt/L� PERMIT # qI ZD l G rl
OWNER'S NAME: o i'1 ucrrgf PHONE # —7'-�n -6`1 Z
GENERAL CONTRACTOR: �' m FAX # 53 3
I am not using any subcontractors:
tyre Date
Please check applicable subcontractor com Tete 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
Plumbing
Roofing 01
Septic Tank
Sheet Metal
Sheet,Roc'k--�
Tile l
r-/2 actor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE O��a c1 09
CUPEkTINO PERMIT APPLICATION FORMit --r
APN # Date:
Jul rT co
Building Address: ( WZ
Owner's Name: Phone #:
�d�n verr .J�3Ck �'Ien 7 � ZZ
Contractor: Phone. License #:
� �r-�,r►a�v bi r� 2S�o(p 18 �2�/ dos''
Contact: one Cupertino Business License #:
d 1 cam- X53 d Lo�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project:
��
Qty. if
'cablp Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
1 BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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