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05120046 (2) CITY OF CUPERTINO '++ M *''f "' "'"" ` BUILDING DIVISION PERMITCbN=I' ` C"1OR� �'�o yamt.',, 4 '.&.'dYux n_ulZ xs.:x.:'LVP¢ ^Lu :r,�*?w"' ts'n"�.4rt2 sN".,u BUILDING ADDRESS: PLUMBERS ON CALL PFJMRNO'05120046 191 KENTWOon AV OWNER'S NAME: PERMIT JESUS DATE GREG DEHAAN 520 M NE: SANTIARY NO. CONTROL NO, 408) 879-9416 ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG O O O joo LICENSED CON1LACIDWS DECLARATION Job Description I hereby afRrm that I am deemed under peOviJw of Chapmr 9(Commencing p l� with Section 70M afDividon 3 of W Belgium amt Profesuons Code,arW my Homes Is in�nll Case ma yarWJhN • 36 { 7 0_ei5t REPIPE FRESH WATER PIPES Dow Conux7or ARCHITECTS DECLIRATION I mbersmnd my plana shall he mal as public menrmis `6V 51� Licensed Pmfesaia..I tB}�� f��3 [[Adgq�wggg OWNER-BUILDER DECLARATION I AL d a a 1 hereby Maso.(Sm that 1 1. =mpg from the Contractors :My C Law for dm \vVi `D o following masa permit g ED L5,c uahm.m and sae,dem ns Code:Any city ar comay $ which requires a Permit re eonstrun,Jim.Improve,demWdh,of repair ed munum 7 5 9(] zy pdorbits Issuance.etso requires the appliesntformebpmmitm Oleasi{mdsupwril €< ti*mmcn co wILhS,menlm0(d.fD bnsafthGConuinbrkLkensGlaw(C edC)CO Sq.Ft. Floor Area �D 1Na[I00 9 tham at I.exempt un and de Dosis for essand on.My 11Cade)or ., Natio u 31.5 b thmefrom and the basis far the alleged ,.Beano M Any violation of sealen T031s by hundred cant Tar.permit subjects the applicant m.evil penalty or p C P } pe Cot mart than Ow hundred dolWs(SSW). T� Hulk Q 1,m owwr of the psoprny,m my wpbycea with mgr u theirmle compewuon„ will dothe worksndlMmmtua is nothumuled oraRertd farmle(Sec.7044,BuMun. Required Inspections and Professions Code:The Caeuanmrs I.iaam law Con Cot apply b owner,ownof q p property who builds or immnwa timamn..nd wM d«s such work hbnsJr or woogh his own employes,provided that men improvements am not inured araaued(mere.IL however,the building or ImprowmCot is mid widunane yea of Completion,the owner- Milder will have Use burden of proving dui he did Cot ddb or Improve for pulp.W MIG.). Q 1.as awns of tM property.are molusiwly eonvuting with licensed Contractor In constmct the project(sec.7044.Business sad Profeubns Code:)The Conuscufs Li- came Law does not apply m an owner of property-who Milds or Improves mMmorm.add. who contracts for such projects with s Con rucmRO llcanad punas to was Contractor's ISeue law. Q l am oamopt undor sec. .B h P C for this mum owner Dam WORKERS COMPENSATION DECLARATION I hereby&ff=under penalty of perjury arc of tiro following declanNm¢ - I haw and war malnmin a Cutinesm or consent b selftinsurt for wodmescompen- 1031C0.'0 ue.u provided fm by Section 3700 a we Labor Code,for tM Perform.of the k for which this permit is issued. I haw arm will maintain Workers Compensation loser .n ngWmd by Seam of the tabor Code.fur the performance of the work fur which tMa permit ts tsmed.Wotkefs C�omP,eLu�atianlmumlm//esniv and Polity numberm:der.1/f¢ `Oise F� Policy No.: CERTIFICATE OF E%EMPDON FRO WORKERS' COMPENSATION INSURANCE (Then scalar need mtbecompeted if the permit u(oranchuMmddollan(SIM) or kai) I anify that in be perfommanCo of We wart for which this permit Is inmtl.I shall as employ anypermn in my munarm u m become subject to dm WorkerCompewWon Laws of California.Dam ApplkanI NOTICE TO APPLICANT:Jr.ager making this Ocsfium of Examining,YOU shwb became subject m the Workefs Compcnmdm provisions of the Labor Code you muss .,O forthwith provisions comply with such provions or this permit mall be deemed naked. z CONSTRUCTION LENDING AGENCY [—r I thereby&M m this mem m acoruvucdon ending agency for the performance of a> Ne work for which this permit is issued(sec.3097.Civ.C.) 14 A Undoh Name z IandefaAddress . V Q i certify that 1 haw read this application and sum that the abew information is ly comma.I agree to comply with all city and county mdin s and sum lam reeding m 0 Wilding caruvuctian,and hereby wthodm mpmsenulwa of this city m CCW UP"gam i17 above-menuumtl Properly for Inspea9m purposes. (We)alum to save,indemnify and keep harmless the City of Cupertino a{Jnst cn liabilities,jud`menW eats and expenses which may b my my we=agJmt aid City V Z in comequtme of tiro Swung of this Permit. r APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE I�AT�Ns. G�/ ice-r— !2 e's Re-roofs Si umAppdianUConutYa Due HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will the applicant or future building=upset sbm orhandle hauNous mauid as de0md by the CupeNm Municipal Cade,Chapter 9.13.and the Health and Safety ANkode,seeuan sss3u.)7 All roofs shall be inspected prior to any roofing material being installed. QYes Will the applicant or fumes building aecupant uac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove h lb. Cors Jr cnnuommut u deft by the Bay Ama Air Quality Mans{omcnt all new materials for inspection. D mu cR QYes Nu I haw mad me hicandommabdadmquremau undcrChapmrQ95 cribs CiRlon niceHeal"Salcty Codc,Sminns25705,25533 md25334.I undcnmd thuiflM Wilding does on,currently have a tanant that It u my mespunsibllity b ratify the aecupsnt of IM mquirgeregentj which benscepdarmiamameof.CmukimofOccupanmy. Signature of Applicant Date 1) All roof coverings to be Class"B"or better oTauthorism agent Dam Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPERTINO Building De artment JOB ADDRESS: f/2 3 f e w Wmco Ave PERMIT # r, Ia0 `? G OWNER'S NAME: Lia PHONE # y©a 97 T- cN 6 GENERAL CONTRACTOR: ftm, &L, , 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 Ask Tile Owner/Contractor Signature Date 41 CITY OF CUPERTINO �'/ L� G - REPIPE/SEW.ERS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # 3-� 3 Zl� Date: Building Address: Owner's Name: Phone #: t7 NAn "/O� Contractor:?/w,m I S Ot` �^ /' License#: 7 / Contact: Q� Oma/ l/� Cupertino Business License #: c.) .2w b-0 Building Permit Info: n Bldg ❑ Elect El Plumb 00-e(;,6 6c9 A! -a-' Job Description: l2tiPlAtd Lv .� � Residential P� Commercial ❑ Cost of Project: k 1 • Qty. if Applicable Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i eofFixtures 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 a 3 2, 3 ` 'o X30 3 . 3