05080216 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR-,INFORMATION lt
BUILDING ADDRESS: AMERICAN RESIDENTAIL SERVI gTND-05080216
30128 METIQ PT,
OWNER'S NAME: PERMIT ISSUE DATE
RISA PICHON 1479 BERGER DR ng /2-i /2Qo5
)NE: SANITARY NO. CONTROL NO.
(408) 287-2165
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I�
lap LICENSED CONTRACTOR'S DECLARATION C+..
1 boreby affirm mat 1 am licensed under prevision of Chapter 9(commencing Job Description/'
^� with Section 7")oroivision3offt Busnessmd Prafeuin�Code.and mylic••s,is A /y,qs A
-oma in mu fame antic _ u y INSTALL 2 WAY C/O & .SEWER tW'%��:CI,}.'Y+ C/O
pqa Date Clazs
O Dale Co.Contreemr C drQ�'
Cp'JJ AR I W use DECLARA
of 1 undersunJ my plans still he tied as public records
>nU
s u.t, Licensed Pmfcuional
03
OWNER-BUILDERmDECLARATION �n(�
a 1 naso.(rfm um 1 1. eemps from the Csomes Code:
License Law for the �� y
o O fallowing reason.(Secuun 70]L5,Business and Pmfessiom Colt:Any city m county It"
<$ which requires a permit bs construct.almn improv,demolish,or repair any sweturt 1/s^ $3208
prior Rs its issuance.also require the applicaolfor such permit to file a signed summent '
€�`e tat he is licensed pursuant to dopmvisioeofu¢Contractor'sLiavcLaw(Chopwr9 Sq.FL Floor Area U(f tl.y✓. Valuation
y (commencing with Section 7")of Division 3 of the Business and Pmfessimu Code)or V Q•�
It R$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects me applicant in a ci Penalty of Occupancy
not more than five hundred dollars(S500). P Y Type
❑I,as owner ofthe pmpeny,or my employees with wage as their sole compensation.
willdo the work and the mecture knot intended or offered formic(Sec.70th,Business
and Professions Cade:The ComumoYs License Law does but apply to an owner of Required Inspections
props ny who bui lds or impmvs thereon and who does such work himself or uuough his
own employee,pmvidcd that such imponatimu art nm;nmded oro@cod for sale.IL
howevr,me building or hoprowmenl is sold within one year of completion,On ownen
builder will him the burden of proving mal he did reel build Or improv for pu pme of
❑1,as owner of On proporry,am exclusively contracting Wim licensed contractors to
construct the project(Sec.7014.Business and Profession Code:)The Conu b Wes Li.
come saw dors not apply in an owner or property who builds or impm,ca themen,and
who convects for such projects with a contractor(s)reamed pursuant in the Contractor s
License Law.
Ej I am exempt under Sea. .B&P C for this mason
V
IC-110"
r Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
I hive and will maintain a CenlRcem of Cmearn to self insum for WorkeYS Compen.
ien,as provided for by Section 37M of the labor Cade,for the perfomtence of the
W
for which this permit is issued.
I ban and will maintain Worker's Compensation Imuran¢,as requited by Section
0ofthe labor Code,for me performance of me work for which ths permit is issu d.
Worker's Comp1e safion 1tm1- ec carrier and Palicy nu artrtier: 5 V�1`L t/1 n Policy No.: '5_01
CERTIFlCATE OF EXEMP ION FROM WORK
COMPENSATION INSURANCE
(This xclion need not bo completed rime permit is form.handreldollars(SIM)
orless)
I ccrti/v Our in the perf nnamec of the work for which mil permit is issued,l shall nut
employ any person in any manner so az to become subject o the Worten'Compewtion
Laws of California.Date
Applkam
NOTICE TO APPLICANT:If.arm,making this Coreficam of Exemption.you should
bttomc subject to me Worker's Compensation previsions of the Tabor Code,you must
.JO forthwith comply with such provisions of this Permit hall ho dcemcd reolmd.
Z� CONSTRUCTION LENDING AGENCY
[-i IherebyaRrre mat there iso comsmdlnn boding agency l'nr the Performance of
> the work for which this permit b issued(Sec.309'),Civ,C.)
Q Iamme.Name
z Lander:Add.
U Q I ceNfy that I have read oris application and sole that me about information is
U, f' correct.I agree to comply with all city and county ordinances and sum laws relating in
O U building construction,and hereby aollorim repma mnisss of this city in curer upon tic
F�
ahovnmcnudgm propertyat for inspection purposes.„y har
(We)agree to saw,indemnify and keep harmless the City of CupcOrst against
res liabiliue.judgmcnumts.candcxpcn..,which may in any way accmc against and City
U z, i,consequence of ung this Permit.
^ AP NT U E AND WILL COMPLY WIT ALL N N-POINT Issued by: .Date
URGE S. ��icJ -per
ere ofA V antract Re-roofs � , b
HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will use,applicant or future building Occupant stem or handle hvardons material
az defined by dm Cupertino Municipal Code.Chapter 9.13,and me Health and Safety
cads.Scotian zss3z(.)7
Ye All roofs shall be inspected prior to any roofing material being installed.
tun thea ream ar rULUM Wilding aero If a roof is installed without first obtainingan inspection,I agree to remove
pP g pant tau equipment or device which P
it hararMe cif cmuminanu as defined by the Bay Arta Air Quality Managcmcnl all new materials for inspection.
iaria7
❑Yes U
I hav mad the houshom ormen.ls requirements underCNPmr6.95 of the Califon
nWlth&SafC1YC Secu 5!505.25111 and 35534.1 understand lhmifme Wilding
:W�Ie 1 M Nn al it is reappmlh111ymnlW ly CG[u lnf meW moraCeuSignature of Applicant Date
r sat ; agent ,m All roof coverings to be Class"B"or better
f Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
UPEI�TINO
Building De artment
JOB ADDRESS:1 0
1 z 8 PERMIT #
o S-0 Z/ Z
OWNER'S NAME: Vsn Yiq\"> tn PHONE # g - Z - zsg
GENERAL CONTRACTOR: jq-_P., C S Q5G a 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 04�R Ci .Rescc�tz r
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Con or Signa fure Date
Sv,
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICEOROF
CUPEkTINO PERMIT APPLICATION FORM
APN# ��Cy Date: Z� d
Building Address:
O o fL .
Owner's Name: �N \ ` Phone#:
Contractor: hone License#:
esc� 6 v y
Contact Phone: Cupertino Business License#:
�U)k 08- 836-stiff
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: r((� r
,V, ! 4 ((/l
r-Vtx5Q ZwA . elo aj W oCsewef w'A G o
Residential Commercial ❑
Cost of Project: h
u aU
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewa a Dis osal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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