05050008 1. CITY OF CUPERTINO
BUILDING DIVISION PERMITrCQNTRACTQR I1Y0 ATIONa,<
BUILADDRESS: ALLSTAR PLUMBING PERMIT NO.
05050008
OWNER'S NAME: PERMIT6SUEDATB
ONE: SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT FLUME MECH
0 0 0
�o o LICENSED CONIRACnOR'S DECLARATION 0�®
(�F{� 1 wrathy affirm Nn 1 am licensed under S DECLARATION
A ION 9(commenting
with Section 7000)of Division 3 of Me Bananas and Professions Cade.and my license is
I.full for¢and effect.
Licensu Class Lk.N DRAIN CLEAN OUT
CO Dem Contractor _ 7-
ZUUS
ARCHITECT'S DECLARATION
V
I understand my plans"I W used As public records
Licensed erebysiand BUILDI (JW"
OWNER-BUILDER DECLARATION ��`�M
I hereby alarm an 1 am exempt from the Contractor's Co License Lew for the
i p O following meson.(Sadat 703 construct,
t,after.and Improve,
de ons Cade:Any city or county
1§2 which reyuirta a issuance.aipermit to u irm,Me alter,i t farsu demolish..sirfile par any structure
Hill„ prior wiuensedpalsu requires Meappthemchpctor's icamn signed statement
<
that he iallmnsaJpursuamwMcprovislomo(teConuacwr'sUmnsaLaw(Chapter 9 Sq.Ft.Floor Area Values[on
6 th (commencing with Section 7000)of Division 3 of the Business and Profnsioni Code)or
l�, $ t m he is exempt themfmm and Me bub for Ne alleged exemption.Any Holston of
Section 7031.5 by any applicant fm a permit subjecu Me applicant m a civil penalty of 3�ero 0 Occupancy Type
tat more Nen Est thumbed dol W(SM.
❑Luownvaf the property,wmYcmployded wOhwagesuthei(rose c .Business
will dathe wah,and Ne he CmaanotintendedoraffnamJ w dosser applya an,Buaimu
and Prafaalobu Code:Thewsttramon,License Law dam tat apply lf rt owner of Required Inspections
propertywho Wlldsarimprow trimnand wnts donaucnwmk MmvlforNmughbis
awneer,Mers.uiping or i pr smhimpmsemnuseenot earofcded mpllerN forMe akc.own U,
huwav,Nebuildingor Improvement Is sold within one year of completion,the ore of
builder will have to burden of proving Nat M did not build or Improve for purpose of
Ask.).
[11.n PVMr of the property,M mehualKly contracting with licensed eantacwn to
mmtmct the pmject(Sec.7044.Business add Profesamu Code:)The Counselor,U.
cense Law does not pply m an owner of property who builds or improv Merton.and
who consents for such Projects with a conmacwKs)licensed pursuant w the Contractor's
Lkensu Law.
❑l am exempt under ee. .BA,PC foute d _
Owner �� Dae
KERS COMPENSATION DECLARATION
I hereby lVarsitr penalty of Perjury am of Me following dalantons:
I lave and will Maintain ACerdOnk of Consent to ulf-insurt fw Workefs Cmdpem
1[3311M
oa,u provideA for by Sudan 3700 of the labor Code,for to performance of Me
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u mquimed by Section
of Me labor Cade,for Me performance of de wmk for which this permit is Issued.
y Worker's Compensation Insdnnce canis and Policy number see:
Carter: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becampleed if Me Permit Is two=hundreddonan($100)
or hums)
1 certify the,in the performance of the We, wck Mia Pe it k Issued,l null am
employanypersoninany.13aa c bject mllnewma yCompensation
Lawsof Califoroi %`I _—• - -• 1
Applicant I 1
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you Mould
become tubjen as to Worker's Compensation provisions of the Labor Cade,you must '
.,O forthwith comply with such provisions or this permit Mall he account revalued.
z CONSTRUCTION LENDING AGENCY
I hereby Affirm that Vert is a construction lending agency for the Performance of
ai the work for which this permit Is issued(Sec.3041.Civ.C.)
G Q Lenders Name
,a z Lenders Address
U0 I modify that 1 have read this application and saes that the above information Is
Ty !' cortec--l agree to comply with all city and county ordinances and seek laws relating to
O rU^ building mnuuNan,and hereby amhodm rtPrexnlativ of his city In enter upon Me
{7.1 above-manmoml property far inspection purposes.
C (We)agree to an.indemnify and keep harmless the City of Cupertino against
fA liabilities,Judgments,cord and expenses which may in any My seams against said City
U'•" min coeq ance of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SygoU'RCE RgE/r�UL�A�TIONS. J
611ature; �ltu� S/ �r� Re-roofs
Signature" plicanuCanwcwr DOW
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wali Me applicant w future Wilding occupant store m handle luvudam material
u dented by Ile CupeNno Municipal Code.Chapter 9.12.and tie Heston and Safety
code,Boca.25532(.)? All roofs shall be inspected pr or to any roofing material being installed.
❑Yea �l u
M911 Me applicant or fumrc building oaupsm use esimpmann at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvudom air comamim ms u defined by We Bay Amex Air Quality Management all new materials for inspection.
Istria?
❑Yes Nu
(have read Me has
ausmakrlabrequimmenH underCMpkrd93 of the Gii(or-
nialkalMkSxfety Come.Satam25505.25333md25534.1un4mand Maifde Wilding
dean set currently haw a Comm,that 1t u my responsibility m notify de occupant of the
myuimmen whinmuat met pdorwissuance ora CerdOnmafOccup Signature of Applicant Date
owneraraamaa'0 All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
&C Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRE�SS PERMIT #
10
3a0
n n Wa4l OSOS'oa ff-
OWNER'S NAME: c PHONE#a�s_ G 7
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
StgKature D to
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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# �S 2 ? O D Date: r O�
Building Address: V
ham,
Owner's Name: Phone#:
Contractor: 7 Phone: License#:
P 1um L f r- a l9
Contact � F ��-Oaov Phone: Cupertino Business License#:
'
Building Pehbit Info:
c
Bldg ❑ Elect ❑ Plumb
Job Description: (/��" .L
Residential p� Commercial ❑ua
Cost of Project:
•
Qty. if
Applicable 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
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