05090025 (2) CITYOFCUPERTINO
BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION
BUILDINGADDRFSS: ACE PLUMBING PERMffNO05090025
R1 0 CANnLEwoon DR
OWNER'S NAME: PERMIT LSSUE DATE
THOMAS BLACK 3160 D 2005
ONE: SANITARY NO. CONTROL NO.
(408) 226-2243
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION
>: C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
sibw with Section 7000)of Divisionlof NC Businecaand Profcssiam Code,and my license is p M A 11 rim(�
j ER'e- imm�fnmeandefreat. REPIPE (FROM METER TO ALE, FAUCETS)
K License CI — Lic.N
Z—o Dam Contractor — �. %t5
qty ARCHITECTS DECLARATION
I understand my plans shall be used as public records -9
3 0 License)Pmfessianal
TZ Z�Q5
`.n OWNER-BUILDER DECLARATION
1 hereby strum that I am exempt from the Contractor's License Law for the LD
r�
iCO e0 following reason.(Section 7(31.5,Business and Pmfessiora Code:Any city ar county P fs��p
K m m which mquims a Permit m enwruct,alter,improve,demolish,m repair any structure `�'�I t` II II' J(f 5600
se
FI< prior to its issuance.also requires the applicant far such permit to file a signed statement
Nat he is licensed pursuant o Be,pmvisions of the Contractor's Berta Law(Chapter 9 Sq. Ft. Floor Area Valuation
z�et (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the,basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
not mom Nan five hundred dollar(5500). Occupancy Type
0 L as owner of Ne property,amyemplomes with wages assecirsrdlecom,mandion,
will do the work,and the machine is not intended or.ffned for sale(Sec.70,14,Business
and Professiors Cade:The Contractor's Lianm Taw dam not apply to an owner of Required Inspections
property who build or(mprows dtcreon,endwh.dasaah work himself.,through his
ow^employees,provided Nat such improvements are not intended oroRerW for We.If,
however.the building or improvement is sold within one year of compledoo,the owncr-
builder will have the burden of proving Nat M did not Wild or improve for purpose of
sale.).
❑1,as owns,of the property,am exclusively convecting with Iiaused...him to
answet Ne project(Sec.7044,Business and Professions Code:)The Convxemfs Li-
aase Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a eomeactor(s)licensed pursuant to the Convector's
License Law.
❑1 am exempt ander Sec. .B k P C for Nis tenon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I haw and will maintain a Confirm,of Consent to self-insure for Worker'sCompm-
137.00
ion,as provided for by Section 37M of the Labor Code,for Ne performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,m required by Secdon
of Ne labor Code,for dm performance oftee work far which this permit 4 issued.
Worker'sCompensationYIwnn��surancelIcarisr and Policy numme,, �Q fi,1 HA.a rv/ Parry No.: O
CERTI IC—SATE OPTION FROM WOR ERS'
COMPENSATION INSURANCE
(This section need not becumplemd mise Permit is Forane hundred donate(SIM)
or less.)
I certify Out in the pc,Norn....I the work for which this permit is issued,1 shall not
employ any person in any manner in as in become subject to the Workers'Compensation
laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exton prion,you should
become subject to the Workers Compensation provisions of the labor Code,you must
.JO fuMwi in Comply with such provisions or this perm it shall he deemed revoked.
'Z'"i CONSTRUCTION LENDING AGENCY
(.�+ I hereby affirm Nat there is a construction lending agency l'm the terfiermancc of
cdthe work for which Nis permit is issued(Sec.3097,Civ,C.)
4 A Lcndcr's Namc
,=Z Under'.Address
U Q 1 certify that 1 hew mad this application and state Nat the above information is
U.P correct.1 agree to comply with all city and county ordinances and state laws relating to
0 C) building convection,and hereby a dmilm rcpresemni es of this city to enter upon the
r Cfl above-mentioned property far inspection puryoscs
(—'1 (We)agree to raw,indemnify and kap harmless Ne City of Cupertino against
y liabilities,judgmems,costs and expenses which may in any way see=against said City
V Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date G—G
SOURCE RE ATIONS. �� /'
��
074 �(IC ��6/ Re-roofs
Signature offiOplicarrWentractor r Dem J
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building acupa^t ours or handle hr,,unous material
as defined by the Cupenino Municipal Code.Chapter 9.11,and the Hedth and Safety
1�'airent.70hich
de, 0 Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑Yes �Na P P Y g g installed.
Will thea applicant or future building If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupant use equipment or devices which g
it hanrdnus air contaminants u defined by tM Bay Area Air quality Management all new materials for inspection.
svicR
QYcs ®Nu
1 have mail Ne hazardous materials requirements under Chapter 6.95 of the Califor-
HcatN&Safety Calc,Sadorts 25305.15533 and Z553d.1 uMervand this if the holding
ts not currently hew a tenons Nat it u my mapomibility m notify the occupant of the
mosts: elplla1toiStualmeOfaconiflem,OfCe x Signature of Applicant Date
All roof coverings to be Class "B" or better
wner or tar au� Date
Community Development
10300 Torre Avenue
H Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
'Plv Cand wood Dr, 0 �oo2—r_
OWNER'S NAME: c PHONE # o�
GENERAL CONTRACTOR: o}C� pjvVWb ^0 I FAX # z
I am not using any subcontractors: 6 yj� 6 A.
Signature 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
Plumbing C-6-
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
SUM
CITY OF CUPERTINO Zs'
REPIPE/SEWERS/MAIN SERVICE
OF
'ICUPERTINO PERMIT APPLICATION FORM
APN # Date:
l 0j 2-- 91611)1-
Building Address:
to C-)m -e W Cr0 j r.
Owner's Name: Phone#:
alacK o2-0
Contractor: Phone: License #:
CC-
Contact: Phone: Cupertino Business License#:
Ta e k-- —
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential torhmer6al ❑
Cost 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 Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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