04030243 (2) CITY OF CUPECONTRACTOR�INFORMATION
BUILDING DIVISIONSION PERMIT ��„�
BUILDING ADDRESS: PERMIT N0,
AMERICAN RESIDENTAIL SERVI ES 04030243
OWNER'S NAME: PERMr1'ISSUE DATE
ONE:
SANITARY 0. OL NO.
ARCHITECT/ENGINEER: arm
BUILDING PERMITINFO
a�ioo LICENSED CONTRACTOR'S DECLARATION - harmIBIS\�
I hereby affirm that 1 am licensed v der provisions of Chapter 9(commencing lob Description APR — 6
wiWScctian 7") fDivisio Sof the dProfcssiurc Conn.and myliccnu is 2004
in fa torte rad tett e �J'�' ��
L7 C u.x I/
Lice Contractor ;Z
Z;:, in - �y •�tj `p�T BUILDING
1 n 11 cC'�S n
a Licensed Pmfcssrona ��
a.BUILDER m do comosco �'"i/"V✓
E 0 0 I hereby.(Gere Nat 1 I.S.eBusin from the Contraetora License law for the
p O (allowing mason. ennot o JIIJ 1. t. I..S and improve,
denutu Code:Any city $county
K$f Vs which requites a permit re cm,s the abet.improve,demolish,m e a signed
ig any airracm
u�'^
prior uiB issuerme,also ecquirn the applicant for CoM1ectoi's icense gaWauemem
that he is licensed pursuant to the pmvisiomu of NC Comncur's License law(CM1apmr9 Sq. Ft. Floor Area Valuat on
z�0 (commencing with Section 7")of Division 3 of din B usiness and Professions Code)or
i $ that he is exempt therefrom and the bssle for the alleged exemp0on.Any violation of
section 7031.5 by any applicant for a permit subjccu the applicant o a civil penalty of 3-AMJtMA`er0 0 Occupancy Type
not Come than five hundred dollars(ML
I.uowar oftk pyvperty,mmy employcu with wagessNei(Sce.70m,11us an,
will Pr Ortwork,end Ne he Coreisnots LMed Lewitt foe Salmpplytoaa, wner of
and Professions Code:The Convenors License law encs not apply m an owner of Required Inspections
property who builds or improves themon,and who does such work himself or through his
Own employee,provided that such improvements are not intended proffered for mile.If.
however.the building or improvement is sold within ane year.(completion,the..it-
builder win have the burden of proving that he did no,Wild or improve for purpose of
sale.).
❑1,as owner of the propcny,am esclusively contracting with licensed convectors to
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li
cerise law does not apply in an owner of propcny who Wilds or improves thereon,and
who Convacu for such projects with a conuacmgs)licensed pursuant to the Conuacmr's
License Law.
I ren e.empt under Sec. B L.P C for Out reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 kmby affirm under penalty of perjury One of the following declarations:
1 have and will maintain a Certificate of Consent 0 sel6imue for worker's Compcn-
motion.as provided for by section 3700 of the labor Code.far the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,sa required by Section
37M Of the labor Code,for the performance of the wmh for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
G ter. 2eL.eG- PoliAsNm.: t/1e N?e6V3"l
CERTIhATEOFEXEM q[J 9ROMWORKERS
COMPENSATIO NSURANCE
(Thu section need not k completed time permit Is forma,hundred dollar(SIU])
or in..)
1 certify Nat in Ne performance of Ne work far which this permit is issued.I shall Out
employ any person in any maturity so as m become subject to she Workers Compensa0on
laws of California.Date
Apphount
NODCE TO APPLICANT:If,after making this Cenificae of Exemption,you should
become subject to the Worker's Compensation previsions of Ne labor Code,you must
,JO forthwith comply wit such Provisions or Nis permit shall k decreed ewked.'
z h CONSTRUCTION LENDING AGENCY
I-+4 I herchy afrem that there is a Communion lending agmey In,Oe Perform..of
!Y> the work for which this permit is issued(Sec.3097,Co.C.)
aA lander''Name
]z Loader's Addmv.
U 1 certify,that 1 have read this application and sue that the above information is
F-' COMM I agree to Comply with all city and county ordinances and sum laws relating to
0 Wildiagconsraction.and hereby auNorine mpreunutiwo of this City in corer upon the
above-(We)agree
property for Impactionunifapurposes.
(We)agree m save,indemnify and keep harmless Omc City of Cupertino against
F-'N Iioilidee,judgmena.case,and expense which may in any way acerae against Mid City
U in consequence of the granting of this permit.
^' APPLIC UNDyRSigNDS AND WILL COMPLY WI L-NOWPOINT Issued by: Date
SOURC ``CC'R'R�//gAyy4JJOO IISS
Re-roofs
S' azure of ¢an✓COn Cor tete
DMATERIALS DISCLOSURE Type of Roof
Will the applicant or future
m building occupant nom or handle hazardous mamnal
as dcfiand by Be Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
admLcodc.Sc,tlori 2553200? InrNo All roofs shall be inspected prior to any roofing material being installed.
❑Y
Will don applicant or fffuture Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes YNo
I have mad the M1onallous materials requirements underChapter 6.95 of the Califor-
nia HCalth 6 Safety Code,Sections 25505.25533 arvJ 25534.1 understand this ifft Wilding
dma not currently have a tenant that it is my responsibility in notily the occupant of the
requirements whim mum M met prior to issuance of Ccnlficae of Occupancy. Signature of Applicant Date
o meranmmdyedag,nt All roof coverings to be Class"B"or better
M
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�.UPE(�TINO
Building Department
JOB ADI)Rtgg PERMIT# 2,,
OWNER'S N u, PHONE iP4 ypoF 41,E ,5917
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 63 —29 ,::s/
e Date
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 Lw
Plumbing ccc c v4 ,Z/S6
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
41
/ ctor Signature Date
CITY OF CUPERTINO
D REPIPE/SEWERS/MAIN SERVICECITY OF
03 6 2 ��
CUPEI�TINO PERMIT APPLICATION FORM
APN #3,S 0 033 �3
Building Address:
lewd ,L-f
Owner's Name: Phone#:
Co ctor: Phone: License #:
ar 02 //M 7,9
Contact: Phone: Cupertino Business License#:
Building Perinit Info: —/
BldgElect El Plumb Er -
Job Descri n:
r
L -Ae r
Residential Commercial ❑
Cost of Proje
Qty. if
AWTi ble 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