04070109 CITY OF CUPERTINO a7475,7 -'x T"+-'
BUILDING DIVISION PERMIT C011,='&RMTORINFORMA'i;ION
B1LDINGADDRESS: ALL VALLEY PLUMBING PERMIT NO 04070109
U0584
OWNER'S NAME: PERMIT nUE DATE
BRIAN LAVELL
ONE: SANITARY NO. CONTROL NO.
(510) 376-4A1 (;
ARCHITECTIFINGINEER
10 376-
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uao LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thus l em licensors under provisions of Chapter 9(commencing Job Descriptio�
n� with Section 7M)of DM.i0n 3 of me B.M.end profcatlons Co sand my license is
in full force and REPIPE
Dam 7/ Conuacbr
As shill ECsS DE LLA N JUL 13 2004
'� 1 understand my plans WII he used u public records
;Q Licensed protons 0nal vUff-Di G
q OW NERBUILDER DECLARATION
3 i F 1 tachy,from that 1 am exempt from the Contnnor's License Law for the
es o following reason.(Schon 703 1.5,Business and Protrusions Code:Any city or county
$ which requires a Permit to cnnsuu t,altar,improve.demolish,or minor any structure ron
�i Prior In its iasuance.alw m,m.the applicant fmsuch Permit to fleasigna)sutount -
�O thus he is licensed punuml I.the provisions or the Comment's License Law(Chapter 9 Sq.Ft.Floor Area Valuana
$ (commencing with Section 7")of Division 3 M the Business and Profcasiona Code)or
that he is exempt thcrtdmrn and the buil for the alleged exemption.Any violation of
Section 7031.5 by Any applicant for A permit subjects the applicant u e civil Pm&hY of �er0 0 Occupancy Type
Am mom than Ron,hundred dollars(5500).
❑I,as owner of Ne property,or my wployeas with wagu As their sole comprnwtlon,
will do the work,end lm atructum la not intended oraRered forsale(Sec.7004,Business
end Profcssmu on
Code:The Cuachn's License Law door not apply to an owner of Required Inspections
property who buildsmrimWom themon,and who doessuchwmk himself orthrough his
awn employeu,provided Nn such improvements arenot mounted!m0@rtd for Wa If.
h..,.Ne building ar improvement is sold within ane year of completion,the owner-
builder will have use,burden of proving that he did not build or improve for purpose of
1,as owner of Ole timpani,em exclusively conmming with licensed co mann s to
construct the project(Sec.7014,Business And Profusions Cade:)The Comncu S Li.
cense law does net Apply in an owner of property who builds or improm themon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Con rtnoes
License Lew.
I Am exempt under See. ,B&P C for this reason
weer Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Nulty of perjury one of the following rseclAatiOns: -
❑I have and will maintain aCcnificam ofConsent to self-insum for Worker's Compere
cation,As provided for by Section 3700 of Ne labor Code,for me Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compeuadon Insurance,as required by Section
3700 of me Labor Code,for the performance of the weak fmwhich this Permit is issued.
My W.:d:i1i Com ensnlon sunny c om,and Policy n cr
Cartier Policy NO.:
LTI•CA : EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb CO.¢ need not W completed if the permit is forane hundred doll.(SI00)
or WAs)
1 certify Nat in Nc perfonanw of de work for which mix permit is issued.I shall nut
employ any person in any manner so as in become subject o the WmIecra Camtteasnlon
Laws of Califomit Dam
Applicant
NOTICE TO APPLICANT:IL after making this CAMFIcale of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you must
.,O forthwith comply with such provisiau or this Permitshall W deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
Fr 1hereby at,.that then is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C)
W� Lender's Name f
7 z lLnder's Address
U Q 1 cenify that 1 love rod this application and sale Net the above informadun Is
It,F conn.1 Agree be comply with all city and county an ounces and sum laws mleting in
0 building convection,and hereby aumorim mprcuntanns of this city to cnur upon dm
W aMvcmcmioncdpmpcny forInspecti(in whichPulp... u tha Crittenden G (We)agree m un,indemnify and kccp harreleCity of Critteen against
c,) liabiliuu,Jursgmena.Costs udexpeues which may in Any wy acme against said City
U Z APPLICANTeo DE ting ND HILL COMPLY WITH ALL NONPOINT Issued by:
SOUR A
Re-roofs
St pili HAZARDOUS MATERIALSDISCLOSU le Type of Roof
Will me applicant or future Wilding Occupant note or handle IuuNau material
As defined by the Cupertino Municipal Code,Chapter 9.13,and the Health And Safety
ode.Sonne 2553247 All roofs shall be inspected prior to any roofing material b ng installed.
❑Yea u
Will the applicant oforum building occupant ule equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
omit haaardouA air mmvninan as defined by the,Bay Amo Air Quality Muagemenl all new materials for Inspection.
Disonet?
❑Ycs
Ihevcmaddahuand usma¢rielsmquimmenaundcr Chspmr6.95ofineCalifor-
nbHcal Loh, 05.25533sm125534.1undersundthatifthc building
dos I e or L t is respo .,y ea Motif Open of c
to tea a nr aceNficae0 Signature of Applicant Date
Ownero,-nmai,<dAgent D,m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
* 't Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JO/B�ADDRE S: PERMI�/�^ /��A
ON VLl
OWNER'S N PHONE j —
GENERAL CONTRA O : FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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 1Y all
Roofing
Septic Tank.
Sheet Metal
Sheet Rock
Tile
/Contractor Signature ate
CITY OV CUPERTINO
Z REPIPE/SEWERS/MAIN SERVICE b o /
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: /1
/0 5 Gv �e Fir CSD
Owner's Name: Pho #
Contractor: /JjL
Lice #:�� T
Contact: j> Cupertino Business License #:
Building Permit Inf :
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project:
Olt
Qty,
A e Fee ID Fee Description Fee Group
PPERMITHE PlumbingPermit Issuance PLUMBING
BPREPIPE Re i eofFixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFDITURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License t BUILDING
2635^�