03090103 (2) . CITY OF CUPERTINO �r S* P^," un ;m� x -3 • r '.
BUILDING DIVISION PERMIT > CONTRACTORANFORMATION L
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BuLONG ADDRESS: CUPERTINO PLUMBING PERMIT N%3090103
OWNER'S NAME: 10297 S DE ANZA BLV PERMIT ISSUE DATE
"E'
(408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30I LICENSED CONTRACTOR'SDECLARATION JobDescri tion
u 1 heresy affirm war 1 am licensed under provisions of Chapter 9(commencing p
x with Section 7IXq)of Division 3 of Ne Business and Professions Core,and my license is
< Licenforteandeffect. WATER SERVICE PINA�.aED
a //
j{=•ai License Clm l0 Lia.g
67 FJF p Dem r Contractor
W3 A CHf1ECr5DECI.A A ION
f I understand my plans shall be excel u puhlic records SEP 18 2003
]yp
5G Licensed Professional
to
OWNER BUILDER DECLARATION
<7 1 herchy Affirm that 1 am exempt from the Contractors License Lew for the BUILDING
O o following moron.(Secdon 703 1.5,Business and Professions Code:Any city at county
S$� which requires a permit to construct,alter,improve,demolish,or repair any seam oc
prior to its issuance.also requires the applicant for such permit to file a signed statement
E Q that helsliccmedpotential tothe provisions nfthe Contractor's LIYOYLaw(Chapter 9 Sq. Ft. Floor Area Valuation
t $ (commencing with Section 7")of Division 3 of the B uiness and Professinm Cmle)ur
n that he b exempt therefrom and the,basis for Ne alleged exemption.Ary=Of of 32641077 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ApN Number Occupancy Type
not mole than live hundred dollen(9500). '' - —' ' — -
❑I.as owner of the prepeny,or my employees with wages As their ole compensation,
will do the work.and the structure is notinsnred oroffered raaaale(See 7W.Badnras 1Ub — SEWEHP� Qjt$�
and Professions Code:The Connectors License Law docs not apply m an owner of 202 - UNDERF V Ul't131 NG
properly who bulldsor improves thereon,and who doessuch work himselfor through his
own employ=,Provided that such improvements tie not intended or offered for sale.If. 301 — ROUGH PLUMBING
however,the building or improvement Is sold within one year of completion,the owner-
builder will have the burden of proving that be did not Wild or Improve for purpose of 302 - TUB & OR SHOWER
"le')' 502 - FINAL PLUMBING ENERGY__
❑1,as owner of elle property,am axclmvdy contracting with licensed conuatum in 506 — GAS TEST
convect the project(Sec,7044,Business and Professions Code:)The Contractors Li.
cense law does not apply b an owner of property who Wilda or improves thereon,and, SO7 — FINAL PLUMBING
who contracts for such projects with a conn clogs)licensed pursuant to the Contractors
License Lew.
❑1 am exempt under Sec. .B!P C for this moon
Owner Data _
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury arc of the following doclaratlons: .. ,
I have and will maintain a Cenifinm of C..ent m selr.umbe for Weaker sComPen-
satwo,as provided for by Section 37M of sale IaWr Code,for the pedormenm of the
w for which this permit is issued.
have and will maintain Workers Compensation Insurance,as required by Section
700 of the%kr Code,for the performance of the work for which this permit is issued.
My Workeh oto enasd nsvmn a artier and Policy number
Carrier. 6t7
Policy No.:
CERTI CATS OF EKEM MON FROM WORKERS
COMPENSATION INSURANCE
mussection nocd not W completed ifthe fermis is for one hundred dnllm(SI B)
or Icss.)
1 certify that in tbe Performance of the work for which this permit is issued.I shell not
employ any person in any mannerse As b become subject to Ne Workers Compensation
Law.of Celirornia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifiene of Exemption,you Mould
become subject to the Workers ComMosation provisions of the lahor Code,you must
D O forthwith comply with such provisions or Nis permlt shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Net there is a coes.vctinn lending agency for the Performance of
1' the work for which Nis permit is issued(Sec.309'1.Co.C.)
YQ Lenders Name
3.z Lenders Address
..j 0 1 certify than 1 ban read this application and sum that the awn information is
y f correct.l agree to comply with all city and county ambulances and sum laws misting to
JO building construction,and thereby authorize representatives of Nis city to enter upon the
W shove-mentioned proV.�d
mpenio urposes.
4 gy (We)agree temnify dD harmless(hc City of Cupertino against
r/) Ilobilitiu,judgme cx res ich trey inanywsy accmc againstsud City
in eonseq ee of iN it.APPLI NT DD COMPLY WITH LL NON-POINT Issued by: Date �- /
SOUR E
Re-roofs
Sig u o o for Dam
HAZAR 10 I DISCLOSURE Type of Roof
,will the vppliesntw tutu ing cupant dem or handle hacallom memrial
as nail sy the Cupertino Municipal,Code,Chapter 9.11,and the Health and Safety
Code. ss3z(a)7
r1yes c All roofs shall be inspected prior to any roofing material being installed.
Ya �u
Will the applicant or future building occupant wee equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hayardous air consminams es defnctlhy the Bay Arta Air Quality Management all new materials for inspection.
dxicl7 /
❑Yes No
IIt read h aNtmsm dal quimmems under Chapter 6.95 of the Caliror.
nice Hcal Saf C .Seed. 550 553and Z534.1tndenunddratiflWWilding
does n to
y be 'amen y mspomthility to nodry,the areuPant of the
requi ch 60 1.cmtific, face y.0 Signature of Applicant Date
r All roof coverings to be Class "B"or better
Owner ram oriruel age Dste
aCITY OF CUPERTINO O o�0�
Gd ' REPIPE/SEWERS/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN# ( I 6-79
9 Date:
/5 . 3
Building Address:0 q
Owner's Name:
-/rJe51 o . X5'7 /D
Contractor: P}one: License#:
12 rto (o .
Contact: Pho e: Cupertino Business License#:
�s S3 -DL 1 (o /
Building Permit Info:
BldgEl Elect ElPlum
Job Description:
Residential Commercial ❑
Cost of Project: /G�D
• J
Qty. if
ApplicFee ID Fee Description Fee Group
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
13MA I URE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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