04110068 (2) a• CITY OF CUPERTINO1*.'s '— `
BUILDING DIVISION PERMIT - hC,ONT, CTORANFORMATION-R
BUILDING ADDRESS: PERMIT NO.
ABLE SEPTIC 04110068
n OWNER'S NAME: FERPAT LEVE DATE -
ONE:
SANITARY OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
,Lop LICENSED CONTRACTOR'S DECLARATION -
� g.uby affil m Nat I am uZadd under vi:inns of Canter 9 commencing _ Job Description -
with��o 7IXk1)nroi.iaion3of du Bait Proressinmeoee.erW mylicense is
"may int B mm�nd xt.` -T-7417 67 REPLACE SEWER LINE
Licenses C ass - -
n1- Dain "i — f Coutdmor
AR HI'IECT`S DECLARATI
wU I Ondcrsuy4Yny plans shall h.used M' sh
,aC; Licensed Professional -
/ OWNER-BUILDER DECLARATION
x i I I QQ�.mhy affirm cel I am eaemyt from the Consomme.Li"..Law for the -
po fullowinl(masnn.(Scc0nn7113 L5,Business and Pvfcssinns C.dc:Any oilymcourt y _ -
K$� which r quires a permit to construct,alar,improve,demolish,or repair any swcmm -
r¢� pri.rmi¢issuance.also mquiretW appliant for such Tcrmitm file a signed summer
< Metbe is licensed pursuant to the provisions of the Contractors License Law chapter9 Sq..Ft..Floor Area -ValuaL
�Fe (commencing with Section 7()0M of Division 3 of the Business and Professions Corm)or
to Net he is exempt therefrom and c..lea for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 7SP�"T*eO 0 Occupancy Type
not marc Nan fisc hundred dollars(5500).
I,as owner of the property,or my employees with wages as Mair sole compensation,
will do Ne work.and Ju structure is out intended or offered for sale(Sec.]DCG,Business
and Profession;Code:'Ihe Contractors Ltmuve.Law docs e.apply m an Owner or Required Inspections _
property who Wilds or improwx thereon,and who doessuch work himselforthrough his
own employers,provided Oat uch improvements art not intended or offered for sale.It.
however;Ne building or improvement is sold within one year of completion.Is owner.
Wilda will have Ne burden of proving that he did not Wild or improve for purpose of
sale.).
❑I,as owner of Ne property,am exclusively connecting with licensed contractors to
consumer Ne project(Sec.7000,Business and Professions Code:)The Contractor's Lt.
.tic law doe nof pply to an own.of property who Wilda or improve daemon,and. -
whocontmcufor such projects with a commaorts)Iic.uued pursuant o Ne Contnetofs
License Law.
I can exempt under Sec. B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby of ind under penalty of perjury one of Me following declaration
-]I have and will mvnuin a Cenifieste of Consent o self-insum fm Worker's Compen- -
ration,as provided for by Section 3700 of Ne Labor Code,for Ne performance of the
work for which Was permit is issued.
❑1 have and will maintain Worker's Compensation brour ome.as required by Schon -
3700 of Ne Latter Code,for Ne performance of the,work for which this permit is issued.
My`Worker's Cnymp�ensatton Insunnee canter and Policy number am:
er: S9L"aTY ;Z7:IBPolicyNo i&2 6W/ 7 _
CERIIFlCATEOFFXEMP170N MWORKERS'
COMPENSATION IN I ANCE ry/ryv e, —0
(Thio uait,n recd not be compleuJ if the permit is(moot hundred dollars(Slap
or Icsx)
1 certify Nm in Ne perfonnenca of the warlyfor which Nis permit is issued.1 shell nm
employ any person in any mannerso u to 111MMM note Subject m the Workeri Compensation
Laws of Cahfomia.Dau
AOplicant ..
NOTICE TO APPLICANT:If,after making Nis Cedifimau of Exemption,you should '
become subject to the Worker's Compensation previsions of the Labor Core,you must
.JO forthwith comply with such provisions or this permit shall be deemed mooted.
Z '-' CONSTRUCTION LENDING AGENCY
Ihereby affirm Nat Nese is a construction lending agency for Ne pedurmancc of
'yv the work for which this permit is issued(Sec.1097,Co.CJ
CL landes Nam.
M Lenderes Address
U Q 1 ttNfy Nu I have read this application add state out Nc ebovu Ofmmarhurt is
" F coned.1 agree to comply with all city and county ordinances and sum laws relating to
0 Wilding coniction,and hereby a.umrim apreamadves of this cityenurupnn the
[k1 ab.oa-um i ned p.Krly for inspection purposes.
(We,)agree to save.indemnify and keep harmless Ne City of Cupertino against
y Iiabiliue,judgments.cosu and expense which may in any wry acrnu against said City
U in cnscuelmocc of Ne granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
i�'�"o Re-roofs
SignatureApplicrat/Comsactor `y Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ju applicant Of future building Occupant store or handh0crypvosNous material
az fined by Me Concordat,Municipal Code.Chapter 9.12.and thvticAM and Safety
Code.SCNon 25532(.)? - All roofs shall be inspected prior to any roofing material being installed.
a6Yes
Will the apmicantor metre Wilding occupant use equipment or swipes whichIf a roof is installed without first obtaining an inspection,I agree to remove
mit hmardous air conmmimout as defined by the Bay Area Air Quality Managcmcat all new materials for inspection.
Duguid?
❑Ycs ON u
I have,mad the harardmts materials mquisem.nts unr.r Cbapor 6.95 of Je Califm-
niaHealN&SafetyCude,Sections 255115,25533 and 25534.1 unumseand that if Ne Wilding
@tea not cunenil have a tenant.Nvr it u my mapt,nsiM1ility m nnuly tW uttupanr of Ne
requimom Ice.mu 4 tett prior m iuuance of a CcniOcau of Occupanry.
�� —off Signature of Applicant Date
eco —
Owner..umnrt er reg=est Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE o cf
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
37S z5ot✓ �/
Building Address:
162 3 2 0 h11/ 3 an A -e
Owner's Name: Phone#60 q�8�2 43_10��
J e 7Yr ,Ja >' ��f W
Contractor: Phone: License#: - 77 y` 7�
A131� 5� ,,7-)-,- ( 3 '7799 aO G
Contact: Phone: Cupertino Business License #:
U wh c. Sura
Building Permit Info:
Bldg ❑ Elect ❑ Plumb J&
Job Description: -
1Z "e 'P9 P-e 5 C w y Z ,P7 k
Residential ® Commercial ❑
Cost of Project:
S ,Soo "
Qty-.--4,f
li abl Fee ID Fee Description Fee Group
PPERMTTFEE 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
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
-27721