05050097 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITaCOtT_z RAQT0R INFORMATION
A„+
BUILDING ADDRESS: AMERICAN RESIDENTAIL SERVI J`gITNo05050097
OWNER'S NAME: PERMIT L$UE DATE
ED
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION ( aaaQQQ 1 O O
m❑ 1 hcrcby affirm that I am licensed under provisions of Chapter 9(commencing Jv—='�
<W with Section?qID)of Division Sof Ne Business and limicasinm Code,and my license is rtlt'-
inrduomeand rr -71 L4� 5 NZ PIPE BURSTING W/CLEAN OUT
L2 Licen a Lic.•
_s Date Com et I- _ N 523 2005
ARCHITECTS DECLARATION
�s I undersand my plans shell be used as public records
J on
;0I Licenud Pm(cssionel �® p���
S OWNER-BUILDER DECLARATION LIytIL9{41t
. <i 1 hereby affirm Rat 1 am exempt from the Cpalraclors License Law for the
INIIIISO
00 following mason.(Section?(91.5,Business and Pmfemiun Code:Any city or county
291. which requires a permit to consort.altee improve,demolish,Or repair any swctum
Fsi
prior o its issuance,also requires the applicant for such Permit to file a signed inurement
that he is licensed pursuant o the provision of the Commcwr's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
z1s-0 (commencing with Section?OW)of Division 3 of the Business and Professions Code)at
$ Nu he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects the applicator o a civil penalty of 37XM9,0tfi13gr00 Occupancy Type
not mole Nan fiw hundred dollars(1500).
I,as owner of the property,or my employees with wages a their sole compensalton,
will do One work and the structure is not intended or offered for see(Sec. Business Required Inspections
and Professions Code:The Comment's License raw docs noe nst apply to an owner of q p
progeny who builds or improves thereon,and who does such work himselfor through his
awn employees,provided that sucn improvements arc not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have dte harden of proving that he did not build or improve for purpose of
tile.).
1,as owner of the pmpeny,am exclusively contracting with licensed mnuacoo to
consumer the project(Sec.TOaa,Business and Professions Code:)The Commicmr's Li-
cense raw docs not apply to,n owner of property who Wilda or improves themon,and
who contracts for such projects with a contnctorbs)licensed pursuam to On,Conhxnor's
License raw.
❑1 am exempt under Sec. .B&P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aMO.under penalty of perjury one of the following declaration:
1 have and will maintain a Conciliate,of Common to self-intim for Worke(sCompen-
=ban.as provided for by Section 37W of the Labor Codc,for Ra performance of Re
work for which this permit is Owed.
❑1 have and will maintain Worker's Compmmation Insurance,as oquiod by Section
37W of the labor Code,for hoc performance of use work for which this permit is issued.
My Worou's CompmosLAationAlnsumnce earner and Policy number are:
crricr:ZLnvf l'Li W A-fe-aa Policy No.: -t_ M*2i0(,,43
CERTIFICATE OF—EX—EM knON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed Rohe permit is for one hundred dollars(5100)
orlera)
I certify that in the performance of the work for which this permit u issued.I shall not
employ,any person in any manner an as a become subject o R¢Wortrn'Compcovtion
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
become subject to the Worker's Compematien provisions of the Labor Code,you must
., z forthwith comply with such provisions or this permit shall W deemed invoked.
z CONSTRUCTION LENDING AGENCY
I hcmbyar0rm Out thcrt iso exhis oioo lcodi isl,,ry rood performance or
a 7 the work for which this permit is Wood(Sec.W.Co.CJ
f170 Lemicls Name
G Lender's Address
az
U O 1 cenify Net 1 bare read this application and state that the above information is
I” cored 1 agree to comply with all city and county ordinances and suite laws relating to
QU Wilding coommetion.and hereby authpme mprexnmives ofthis city to corer upon Inc
ra m
atow- entioned property for mp
itenion proposes.
(We)agree to save.indemnify and keep harmless the City of Cupertino against
E'N liabilities judgments,costs and expenses which may in any way accrue against mid City
U z inconsequenccofthegrami of rmit.
'^ APPLICANT UNDWILL COMPLY WITH ALL NON-POINT Issued by: Date
NEv
SOURCE REG TIO
l�� Re-roofs
armor ApplicmUC nrKor, D,
H MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuom building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
ode.Sc yxx 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yn VQ
Will the applicant o atom building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove.
h haysdins air comm m as dcfned by de Bay Asa Air Quality Management all new materials for inspection.
Disport?
❑Yes �Nn
1 no.real the horibil
,us materials reyuircmenm under Chapter 695 of the Califon
niaHwlN&SafetyCotle.Section 255(15.1 533 an12553a.l undersand dun if 0te Wilding
dao Out Connolly h ouni.or in,rn,.,bili.y It notary Ra:rupant of led
mquimmcna m ormismanceor,certificaanron tynacy. � Signature of Applicant Date
mamWd'red set Dae All roof coverings to be Class"B"or better
e Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT#
OSoSoo t-2
OWNER'S NAME: pL `e PHONE # ( vo
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: lg 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
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contrctor Si Date
an
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE 6VO
CUPERTINO PERMIT APPLICATION FORM
APN # 37r
24 5 f OS
Building Address: 1
Dv-
Owner's Name: Phone R.
KAr
o 15
Contracto ��'�., 2�SYo(ev fw, i Phone License
l4mlev7 l4 t S Z
Contact Phon : Cupertino Business License#:
JO Z v
Building Permit Info: 0/`7v"11
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential P I Commercial
Cost of Project:
Qty. if
Applicale 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
l BPSEWER Sewers. PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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