03090069 (2) • CITY OF CUPERTINO ^•' �°•:a�zas�xa a
BUILDING DIVISION PERMIT CONTRAC rl�R INFORMATION
BUILDING ADDRESS: ACE PLUMBING v PERMIT N0b309OO69
I -A KENTWOOD ANT
OWNER'S NAME: 6307 MOUNTFORD DR. FERMa ISSUE DATE
HE SANITARY NO. CONTROL NO,
(408) 226-2243
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
loo LICENSED CONTRACTOR'S DECLARATION
w F I hereby affirm that 1 am licensed under provision of Chapter 9(commencing Job Description
U with Section 7M))of Division 3 of the Business and 1./ tm�. ..ad licomc is
in full Come and e i., C _ MAIN SEWER LINE WATER SERV
qc License Class contractor / OhMALrso
m ARCH1=S DECLARATION
4 W U 1 understand my plans shall be used as public records
LL LittnsedPmfcaionel SEP 15 2003
-v, OWNER-BUILDER DECLARATION
jay 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 1831.5,Business and Profcasions Code:Any City or county �'0 LDn'
<' mim
m� which requires a pert construct,alter,improve,demolish,or repair any structure
°ir prior o its issuance,also requires the applicant for such permit to file a signed.vatement
that he is licenseda a uant to the roisioof the Contractor's Liceve Law(Chapter 9 S Ft. Floor Area
«C (commencing with Section 7 )or Division 3 of the Business and Professions Codicil or 9' ValU3IlOn
r3$ Nat he is exempt therefrom and the Whis for the alleged caemption.Any violation of 35931025 . 00
Section 9031.5 by any aflowantfar a permit subjects the applicant to a civil penalty of qpN Number
not mom than five hundred dollars(sN10). - - - - - --- - Occupancy Type --
❑ 1.as owner of the Property,or my cmployca with wages as their sole comprnsation,
will do the work,and we,vuaure isnot intended or offered far age(Sec.1044,Business _
and Pmfcssions Code:Thc Contsaaors License Law docs not apply to an ownet of CttI ❑
property who builds orimproves thereon.and who does such work himself or through his 502 — FINAL MBIN ERT RGY
Own employees,provided Chat such improvements are not intended or offered for sale.If. SO7 — FINAL PLUMBING
however,Ne building or improvement is sold within ane year or completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
a�lc.).
W'•as owner of the property,am exclusively commed,with licensed convectors to -
mmwct to project(Sec.1(P44,Business and Profcaions Code:)The Contractor's Li-
musi,Law dors not apply Co an owner of property who builds or improves damon.and
who contracts for such projects with a conlraclor(s)licensed pursuant to the Contractor's
License
C] 1 am c cr Sec. B h P fo�Chis�azo�n
J Date_g
WORKER'S COA NDECLARATIONl T--"
1 hereby affirm under Penalty of pejury one or the fallowing declarations: -
1 have and will maintain is Cmificzte of Consent to self-how.for Worker',Compen-
sation,m provided for by Scion 37W of the labor Code.far the performance of the
work for which this prmil is issued. -
❑1 have and will maintain Worker's Compensation Insurance,as required by Sermon
37W of the Labor Crew.for the performance of the work for which this Permit is issued.
My Worker's Compeaation Insurance carrier and Policy number am:
Cartier: POI icy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less.)This section need not W completed if the permit is for one hundred dollars IS 1010
I certify Chat in the performance of the work for which this permit is issued,1 shall not
employ any Person in any mann,,ah as Co become subject to the Workers'Cnmpa¢ation
Laws of California,Dam
Applicant
NOTICE TO APPLICANT:If,alter making this Ccnilieak of Exemption,you should
became subject to the Workers Compensation provisions of Che Lana Craw.you moa
z forthwith comply with such provisions or this pwrmil shall be deemed winked.
Z O CONSTRUCTION LENDING AGENCY
Zi I hereby affirm that there is a eommactina lending agency for the performance of
]d 7 the work fur which this pcmrit is issued(Sce.3097,Civ.C.)
4 15 Lender's Name
2.
Z,Z Lender's Address
J Q 1 comity that I have read this application and Mute that the about information is
yF
comet.1agree d comply with all city add county oNinan esandsate laws taring to
JU building construction,and hereby authorize representatives of this city to enter upon the
til abevifta, *Tal property for inspection as which may
gy (We)agree to ave,indemnify and keep harmless the City of Cupertino against
z Iia bilitica,'udgmcnu.cosu end cxP-tics which may in any way accede against said City
J Z in con enc,of the graining o[Ihis permit.
^
APP/X4NT UNDERSTANND WI COMPLY W TH ALL NON-POINT Issued by: Date
S REGULAT 5./
Sig teofApplicanVConractp Date Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or[.Lure building occupant sore or handle hazardous material
az defined by the Cupeninounwipal,Code,Chapter 9.11,and he Hcahh and Safety
Code,Section 25532Ia)l
❑Ye, Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building«,apart use equipment ordcvi«s whim If a roof is installed without first obtaining an inspection,I agree to remove
fit hazardous air contaminants as defined by the Bay Area Air Quality Management .all new materials for inspection.
District,
C]Yes �No
I have read the havardnus materials requirements under Chapter 6.95 cribs,Califor
ria Health& ctyCadc,Sectimss 25X15.25533 Nd 25534.1undcroardimcifth,buildin,
doa no ndy have a,nam.Nat iC is my Fponsibility w nndl'y CM occupant of the
rev Law nmuube dor sissy oracadB,agro Signature of Applicant Date
Owner in auhoracd agcn lI p All roof coverings to be Class "B"or better
1
CITY OF CUPERTINO 3 7 6
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # 3 --5—
p � / te:
Z L Da (�
Building Address: / J
� WO OJ F1Vt f
Owner's Name: Phone#:
Contractor. tq CCPhone: WOOLice #: 1
Contact: t— Phone: Cupertino Business License#:
,Nr sc, 2
Buil ermit Info:
Id Elect ❑ Plumb Lel
b D ption: M/4rA"in��S SW�
Residential Commercial ❑
Cost of Project:
Qty. if
A 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
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
i 19 �z