04030174 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC"�T.OR�INF'ORMATI
ON :'
i
BUILDING ADDRESS: PERMR NOD 4 0 3 017 4
OWNER'S NAME: PERMnISSUEDATE
ONE:VENU RANDA
SANITARY 114: OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION
C 1 hereby affirm that I am licensed under pmvisions of Chapter 9(commencing Job Description
b wiNScction]").fDivision3offt BusinmtnlPro(ossium Code.mdmyliccnuis
_,aa, imfull f e dcfL"L36 ✓`l V92 Sia REPIPE
0 a z LLee
ntt g�,
ZZ 'c Ind, S ro — CONTRACTOR: A-1 PLUMBING & HE ALE
t2 ARCHITECTS DE LA ION
1 un rstand my plans¢hall W used u pts c records
LLO f, L'mcnttd Professional
MARL 5 2004
.�cS OWNER-exempt fr mDECLARATION
c I hereby affirm Nat 1 1. exempt from the Contractor's :License Law for Na
O O following acres..(section]1131.5.Bm;ness and Profe item Code:Any city Of county
which mqusd a permit m Corry tha alma,rat haste demolish,or repair any tata.. BUILDING
ement
prior it)its issuance.alsomquithe the inion o hasuch Law naumcm
iG
that Wiseing adPursuantto the 7")of Dwiotn of the Convaaurind Professions
CharterCodi
Sq.F[.Floor Area Valual)On500
cot•$ (mmmatcing P'thectiont anduse, i.is for of NCBusi errand Professions Cable)or 4L
Nat tor,Lot exempt Nertlrom and the baso for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant far a Lamm,t subjects Ne applicant an a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(S500).
❑I,downaaf Ne pmpcny,amy employes with wags utheirsolc Compemedon, 36224040 . 00
will do ds,work.and Ne swaurt isnot intended mothered!hassle(Sec.]Ora,Bu9ness
and Pmf.io.a Code:Tha Cmamea rs License Law docs out apply to an owner of Required Inspections
progeny who builds or improver thereon,and who doessuch work himself orNrough his
own employees.pmvidcd that such improruments arc not intended oroQcred forsalc.If.
howesmr.Ne building or;mp amment is sold widtm am year of Completion.Ne owner.
builder will bane the burden of pouving Nu he did not Wild or improve for purpose,of
sale.).
❑1,as owner of the prepeny,me esclmively contracting with licensed convectors in
consumer the project(Sec.]Bra.Business and Professions Code:)The Camases:Li-
come law dors not apply to an owner of property who Wilds or impound Merton,and
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑I sm exempt matter Sea B&P C red this resson
Ow r Dam
WORKER'S COMPENSATION DECLARATION
1 hereby of mar under penalty of perjury no of the fallowing declarations:
. L]I have and will maintain a Certificate of Consent in self-insuafor Workers Compen-
usion,as provided for by Section 37W of the labor Code.for the performance of the
work for which this permit is issued.
❑1 hale and will maintain Watrrs Compensation Insurance,as required by section
37W of the labor Cade,for Ne performance of the work for which this permit is idued.
My Workers Compenrauan lnrmutee cortin and Policy numW arc:
Pa,;cyyA A/�f0/da3
CERTIFICATE OFE EM Pr1 Xq(;MWORKERS'
COMPENSATION INSURANCE
rrhissection reed not wcomplemd if floe permit is forone hunaeddollars(SIM)
or less)
1 certify that in the performance of Nc work for which this permit is issmd,I shall not
employ any person in any mannast as in become subject of the Workers Compcnration
Laws of Ci liromis.Dau
Applicam
NOTICE TO APPLICANT:If,after making this CcoiOcale of Exemption,you should
become subject to the Worker's Compensation provisions of Ne Labor Code,you most
.,2 forthwith Comply with such provisions or this Permit mall W deemed mvoked.
zO CONSTRUCTION LENDING AGENCY
PI hereby M.Net them its consttaction lending agency far the performance of
the work 5� k for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
ddress
V6. comers Agrees
C) I eeniry that 1 have mad this application and sum that the shout infoonnomn is '
cormin 1 agree m comply with all city and county nNinanas and suite laws r upon t e
pv bu;lnmenttswctiamand yhereby auNonpr representatives of fur city mcnuruPnn the
Y'W aMve(We)areoned pto property for insrify an keepbs
(We)agree m on,;nde expenses
end keep harmless be City ru Against said
agaid City
Fesi,LZst
in Consequence
enceo nts.costsag of this
may in any way eccouc againstsaid City
(„)z A PLI(;6 T of thegranting of Nis permit.
^' APPLIffffff,,,,,,//////...���NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 4Da3t
SOU}QER U 345.
Re-roofs
Crime S nuurt of ApplicmUCoDau
HAZARDOARDO US MATERIALS DISCLOSURE Type of Roof
Will the applicant Cupertino
err future Wilding occupant nom or handle hmrNous material
az deserted by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ale,section 23532(¢)? 111111 All roofs shall be inspected prior to any roofing material being installed.
Yd N.
Will the applicant or future building oacu ant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
lC/ nn s p Area
•mit District? nus air contaminants ns dc0ncd by Nc Bay Arta Air Quality Management all new materials for inspection.
D vin]
❑les No
1 have mad the hammous maudals requirtmenu under Chapter 6.95 of the Califor-
nix HeslN&Safety Code.Sections25505.35533 and 25534.1 unaemant One ifdm building
doer Iro urmntI haze a mnann Mar it u my responsibility m maily the occupant of the
myvi =ntswhin slWm=
do,toawsmce.r.cenlfiauafoeple.7. Signature of Applicant Date
l�
aapNaa,<dasen� Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEI�TINO
Building Department
JOB ADDRESS:. pI/
I/07 L° PVYLUNFOIf U&MIT
OWNER'S N PHONE Ly�'
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
r-owffi Contractor Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN #
Building Address: �qy C'QeSTvJvF
I JJe. UReeTiNO C A 902
Owner's Name: Pho e #:
V All 6ANb� ��roBJ 2- -i,sy(,P
Contractor: Phon : License#:
A-lPL✓nv6.Na{N1Q1T/NL �6s�, 36Q yotz Vd?2f?v
Contact A. Phone(G�J 69 yo1L Cupertino Business License#:
Building Permit Info:
Bld97 g Elect ❑ Pl
Job D scription:
r
Residential ❑ Commercial ❑
Cost of Project:
Qty. i
APPIX*Ie Fee ID Fee Descri tion Fee Grou
PPERMTI'FEE PlumbingPermit Issuance PLUMBING
BPREPIPE Re i e of Fixtures v PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING