05050158 (2) CITY OF CUPERTINO A.
BUILDING DIVISION PERMIT CONTRACT OR INFOyRMATIO.N ,
BU ILDING ADDRESS: TRIPLE A PLUMBING PERMIT N005050158
OW NER'S NAME: PERMIT MUT DATE
HMS_ DF.VFT OPMFNT TNG'
ONE: SANITARY NO. C OL NO.
(6SQ) 964-49-AS
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
a�ipp LICENSED CONTRACTOR'S DECLARATION
wC I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
iW with section 7MK))of Division 3ofthe Busirvand Profession Code.and my licenp if
in full room and
;'q= Licenac Lic.11I REPLACE WATER LINE (METER TO HOUSE)
Contactor-I lov-1K, 11 �11fiffr1rWr
I ARCHITECTS DECLARATIDN I N1
>? I understand my plans shall M used as public records t/�@t�pl
,6u FINALE,,,,
LE®
''o t; Licensed Professional
3 OWNER-BUILDER DECLARATION
y 1 Mreby affirm Nm 1 am exempt from the Contractors License Law for the
00 following mason.(Section 7031.5.Business and Profession Code:Anyeity or county '
ae$ which rent.a permit m ennsWct,alter.improve,demolish,m repair any W.enum AAO
F_eprior to its issuance.also requires me applicant for such permit m file a signed somment
Out M is licensed pursuanuo the provision of Nc Contractor's Usense law(ChsN.,9 Sq.Fl. Floor Area a sea Valuation
%F0 (commencing with Section 7(100)M Division 3 of the Business and Professions Code) '
i Nat he is aempt therefrom and the basis for Ne alleged csnmptioa.Any violation of
Section 7031.3 by any applicant for a permit subjects she applicant to a civil penalty of
ctrl moe Nn five hundred dolas s500). 3 er0 0 u ane Type
I,a owner of the property,or my employees with wages a their sole compensation,
will do the work,and Ne swanre is nor intended or offered far sato(Sec.70a,Business
and Profession Cox:The Contaemrs Liaise Law dW not appty to an owes,of Required Inspections
property who builds m improve thereon,and who docs such work homelier through his
own employees,provided Nat such improvements am not intended or offered for sale.If,
however.the building or improvement is sold within on year of completion.the owner.
builder will have the burden of proving Nat W did oat build a improve for purpose of
..le.)
1,as owner of the property,am exclusively contracting with licensed contractors to
convect the Pject(See.7044.Business and Professions Code:)The Commam rs Lb
case law doe not apply or an owner of prolat"who Milds or improves thereon.and
who contracts for such projects wish a eonuaeems)licensed pursuant to the Contractors
License law.
❑I amaemptunder Sea. ,B&PCfur Nisreasun .
Owner Data
WORK ER'$COMPENSATIONDECI RATION
1 hereby affirm under penalty of perjury one of th following declaration:
1 hsm and will maintain a Certificate of Consent o alf-insum for WorkertCompen-
- 55tion,u provided fo by Smion J700 of Ne Labor Codc,rat Nc Performance of the
work for which Nis Permit is issued.
0 1 have and will maintain Worker's Compensation Insufanc,at required by Section
3700 of Ne laMr Code.for Ne performance of Ne work for which this permit is issued,
My Work Cn,glpensatin ilgpsuance comic,and Policy number am: p
Cmrier. IvJ�r Y� �n f Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusection need not M completed if the permit is forone hundred dollars(SIM)
or loss.)
1 certify Nat in the performance of the work for which Nis permit is issued,I shall not
employ any person in any manner se,u to become subject to the Workers Compensation
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If,after making this CeoiOcam of Exemption.you should
become subject m the Worker's Compensation pmoisim,of the Lahr Code,you must
Z, foMwith comply with such provision or Nis permit shall M deemed revoked.
z O CONSTRUCTION LENDING AGENCY
'Tr I Mneby affirm that there is a construction lending agency for Nc Nrfurmamc of
Qi the work for which this permit is issued(Sec.3097.Civ.C.)
ft)
Lender's Name
6. Lender's Address
5z
U O 1 certify that 1 have read this application and more Nat Ix show information is
D, f come"I agree to comply with all city and county ominamms and sum laws relating to
pU Wilding convection.and hereby authprire reprebotativu of Nis city to enter upon the
r W alow-menuoned property for inspection purposes.
(We)agree m save,indemnify and keep ss did,City of Cupertino against
H raj) liabilities.judgmcas,costs and expersa which may in any way scene against sod City
UZ in sequence of the granting Nis permit.
^ APL CANT UNDERSTAN AND WILL COMPLY WITH ALL NO''-POINT Issued by: Date
S E U ttt
ATIONS.
Re-roofs
t pure or Applicant/Con or Dam
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will Nc appiicam m foure MtiOng occupant sure or handle hazardous material
as defined by the Calandra Municipal Code.Chapter 9.12.and the Health and Safety -
Cale,section 255J2(a)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yet Nn P P Y g g
Will theapplicant or future buildingoccupant use uimens or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havmnus air conuminans u de0ncd by she Bay Area Air Quality Management all new materials for inspection.
istrier?
❑Yes 01/
Ill...M
the
wardnusmverialsrequim=nm under Chapmr6.95 of dm Califor-
d Seemosm 5.25533and25534.1uMcrsund Notifthc Wilding
w tenant,thatitis myresprnibilitywnoulythemeupantofthe
u est nortuissaanccid.ccnftcam cull e�/ Signature of Applicant Date
or Fent Date All roof coverings to be Class "B"or better
x Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
OB ADDRESS: PERMIT #
nv
SGS G/S`
OWNER'S NAME: 5 PHONE #
GENERAL CONTRACTOR: bi tA #IaSD
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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 Au rahna
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
1,l
Owne /Contractor Signature D to
CITY OF CUPERTINO
a
REPIPE/SEWERS/MAIN SERVICE
® CUPEkTINO PERMIT APPLICATION FORM
APN# h Date• /
�3
Building Address:
wner's N me P one#:
ntractor: Phe: ` License #:
RXZ
Phone: , `� Cupertino Business License #:
J
wilding Permit Info:
Bldg ❑ Elect ❑ Plumb
,Jpb Description:
Resi ential loommercial ❑
Cost of Proj :
Qty. if
Applicable 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
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
7s�
L� 7- 3 �