05110037 CITY OF -
BUILDING DIVISION PERMIT CO a RAGTOIi INk'ORMATIO;N ''
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BUILDING ADDRESS: PRO ROOTER PERMRN0.05110037
10641 ZNDERLICH DR
OWNER'S NAME: PERMIT ISSUE DATE
MIKE SMITH 2306 AMERICA AVE 5
�NE: SANITARY NO. CONTROL NO.
(510) 670-1115
ENGINEER: BUILDING PERMIT INFO
BLDG EIFCT PLUMB MECH
0 0 0 0
LICENSED CONTRACIORS DECLARATION
I to w 1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing lob Description
with Section 7")of Division 3 ofthe Business and Potemkin,Code.and my license iS �II A
imm�m«and �)r REPLACE SEWER tLtINE NI ALL C/O
Liccnac Clan
L.'--6
k• Wlf�v�� [J f�
' p Date
ARC
HTIECfS DECLA A ION Clff g" yy�/
I m I um en red my plans shall be nuts u public memen /
3a� Nov -�nn�
s O Licensed Ptefee Tonal
3 OWNER-BUILDER DECLARATION PUP
tj i 1 hcrtby aRrm Nm 1 em.Bumph Imre the fes outors I:Any c Law for the 1' {j I( ,
O O following reamn.(Section]IIJ L3,Business and Pmfessians Cak:Any rily at county �p3 F�j1j it
5$� which requires a permit to centime,apes.improv,demolish,or repair any structure n r7, $2900
Zy prior w its issuseae.also requires the applicant for such permit to file aligned stwmmt tau V
o tharhcitfcerandputxoanuotm PmvisiamofwecommemsLimoahw(Chaplm9 Sq.Ft. Floor Area �'' Valuation
(commencing with Section 7W)of Division 3 of the Business and Professions Code)in
.0 that he is exempt thmpfrom send the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy Type
not mart than flue hundred dollars($300L
0 1,as owner of the property,in my employees with wags as then sole compensation,
will do the wort and the ihamurt is not intended in afartd fored,(S..7oaa,eushuss
Required Inspections
and Pmfemi0to Code The Counselors License Law do net apply to aan man'of q P
Property whobuilds m haps'.thereon.and who doc,mch work homelier through his
own employees,provided that such ireprowmencs tient intended"Offered for sale It.
tly s �:+• S
lumm,ethe Wildingarimpmsanmtwi
iswidN omy ofmmplcdm.lbeownv- _"�� ,_ ,
builder will suave the harden of proving that he did not build or improve for purpose of
ark.).
1,as awmn a the propeny,am aelusitely contacting with licensed centracton he Nr r R +n
construct the Project(Sec.70aa,Bus nest and Professions Code:)The Comeacuws U.
come taw does not apply to an owner of propeny'vha builds or improves thereon.and, T�
who contracts fat such projects with a convcwr(s)licensed pursuant in the Comracutes BUY,
9 ,
Li,..mu
Law. Ird�y^..w,1JAC J y ♦ v yu., hi r'•'b.r
❑laemptundm See BaPfmreawn. Cthist t •Ca
wear Dan
WORKERS COMPENSATION DECLARATION
1 hereby allure under penalty o(pedury one of the following O,claratiov:
1 haw and will maintain a Certificate of Consent to self-buaurt for WoMYs Campion.
an
as provided for by Section 3700 of Ne Labor Code.for the performance of th,
wort for which Nis permfl is inuN.
❑I have and will maintain Worksh Compensation Insurance,as required by Section
37wof Oc labor Codc,for the performance of the week for which this pcnnit is issued
My Waiters Ca/m/p` rance a 'mania.hasuan Policy number are:
Carrier. UA r/If��/' 1!'�� Na.: 5
CERTIFICATE OF EXEMPTION FROM ORI( R
COMPENSATION INSURANCE
mils section need het W completed Von permit is fmarc hundred down(SIM)
lm)
I certify that in tee poli m use.of the work for which this permit is issued 1 skull ooh
employ any person in any maonerso as to hawses subject to the Wuftex Campevauon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Worker's Compcvadon provisions of the Labor Code,you most
Q z foMwith comply with such provis ons m this permit shall he d¢nted mated.
z CONSTRUCTION LENDING AGENCY
(-+'+ Ihereby affirm dhu then is.emoruction ktiingigms,far the performa cuf
a the work for which this Permit is issued(Sm.3037.Civ.C.)
1 Q tender's Name
z Lenders Addnus
V Q I certify that 1 haven read its application end sum that the atom infmmatiun Is
U. coned.I agree to comply with all city and county mtlnanRt and teals laws Rlatng in
Q building construction,and hereby autbona:repoesrnerahm of this city to enter upon tho
a...... nduneu property fm ivpeduon purposes
fr"C6 (We)agree to sive,indemnify and keep harmku the City of Cupertino against
cn liabilities.judgments.costs and mpenus which may in any way accrete against said City
t)z in consequence of the granting of this permit '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:34toAa Date
SOURCEREGULATIONS. b II ORe-roofs
Signaurt ifA lican iouseor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the
'oil ret or future building occupant non m handle hrsov material
ss dcfned by the Cu -in.
Municipal Code.Chapter 9.12.and Ne Health and Safety
refs.Section 2533xp)T
❑Yes 7rNa All roofs shall be inspected prior to any roofing material being installed.
r If a roof is installed without first obtaining an inspection,I agree to remove
Willapplicantorauto as
building occupantaseequipmentser which g
mit hmardoes v air contaminantsu dcfinN by We Bay Area Air Quality Management all new materials for inspection.
DiminT
❑Yea Nu
I have read the hvavdoua cu mriabrtquiremenu under Clap ord.95 ofthe Califer.
nk Health k SaletyCede,Stt7imu 25505.x553]and 25531.1 un�mmod Na ifthe building
docs not currently hew a imam,that it k my rcaposchility m hmuly the occupant of tee
ragaircmmu which maaype met prior iisahmafa cwficam of Oc/��yy.� Signature of Applicant Date
ownerenuth acdagcnt �/l / m All roof coverings to be Class"B"or better
r
Community Development
00
orre Avenue
F>
r J 103
peertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: I^/���E�Grn" PERMIT #
to UV SLI GS110o37
OWNER'S NAME: PHONE # - 75-0 0176
GENERAL CONTRACTOR %d FAX #
I am not using any subcontractors: �O�Ud (D17�1G�4 AO
r�Signature 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
Su
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE aj-11 '963r
,CUPE(�TINO PERMIT APPLICATION FORM
APN # 3753�o�a Date: '
D o5
Building Address: 106 VvvA/PnR�CH
Owner's Name: V� /u Phone #:
5/11 f 5-531-501
Contractor: h� OVI� IIVC Phone- 750 _QC� Lice���5�
Contact: 'I�^I� M�� Phone: /C �So tea ! Cupertino Business License#:
Building Permit Info: lJ� D
Bldg ❑ Elect ❑ Plumb
Job Description:
eN( OF I/T O ree7, oF MSI s-a4ew C F �1 ne
Residential 1ACommercial ❑ At$o W0- cGEhr 007-
Cost
vTCost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING.
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
�k 307' '?