03110042 (2) I CITY OF CUPERTINO
BUILDING DIVISION . PERMPI' CONTRAOTOR INFORMATION
BUILDINGADDREss: CUPERTINO . PLUMBING PERMIT NO03110042
OWNER'S NAME: 10297 S DE ANZA BLV PERMIT ISSUE DATE
MARIO DORTENZIO 3
NE` (408) 253-0618 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300
LICENSED CONfRd under
DECLARATION
I hereby affirm that 1 am licenced undo.provisions ofs Cm 9(commencinglam.s Job Description
with Section of Divislon3of me Business and Professions Cnde,and mylicensc is
mmnmreeandermct. Lzy�C 5' REPIPE & WATER SERVICE
qz Liaerm -Capp
p Date //• r// (/O aolraLlnl
C "<� ARCHITECT'S DECLARATION
e U 1 undcrstand my plansahall he used as public records
0
o Licensed Pmfcssionel
3 OWNER-BUILDER DECLARATION
iF 1 herehy olErdn that I am exempt from me Contractors License Law for the
p p fallowing mason.(Scedon 8131.3,Business and Professions Code:Any city or county
<S ff which requires a permit to construct,alter,borrow.demolish,an repair any structure
prior or its issuance.also requims the applicant for such Permit u file a signed statement
¢¢s< that he is licensed pursuant to IN provision of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
zt-0 (commencing with Section 7000)of Division 3 of the Business and Professions Creole)or
y ..
that he is exempt therefrom and die basis for the allcgcd exemption.Any violation or 32643013 . 00
Section 7031.5 by any applicant for a permit subjccu the applicant to a civil penalty of APN Number Occupancy Type
not mare than five hundred della.($500).
1,As owner of the pmpcny,or my employees with wages u Nein sole compensation,
will do to work,and the structum is not intended or offered for sale(Sec.7044,Business
And Professors Code:The Contactor',License Law does not apply to an owner of Required Inspections
own employees,
who boils or The
chicon,and who does such work or offered
eor dth r ale.I.
owneer,the buildinprovided imrmelt improvementsarenot intended moffered fur sale.owner.
however,the building or improvement i,old within one year of completion,Ne eof
builder will hare Ne burden of proving Na he did not build or improve for purpose of
0 1, -
co s u owner rd the Sec.70,I ,B exclusively contracting with:)TheeConru tor', i.
cause La the project(Sec.]044,Business and Profusions d&or mo The Convectors ul
wholaw cts F not apply a in owner of property who sed p or improvee theuan.and /
who se Latta for welt projecH with aconvacmrts)licenser pu.uam to the Comnnors
License Law.
�1 am exempt under Sec. .B,k P C for this rtsson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCampen-
sation,v provocd for by Section 3]00 of the Labor Code,for the performance of the
wo k for which mi,permit is issued.
have and will maintain Worker'%Compensation Insurance,n requited by Section
311 of the Labor Code,for thc performance of the work for which this permit is lamed.
My Worker's Compensation Insurance carrier and Policy number are: .
Cati t' N�Poli a: 00071 c '
CERTIFICATE OF EXEMP NF MWORKERS' '
COMPENSATION RANCE -
(This semmr need not be completed if me permit is for one hundred dollars(SIM)
or len.)
I certify thea in the performance of the work far which mis permit is issued,I shall out
employ any penton in any manner so u to become subject to the Workers Compensation
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If.after making this Cmificne of Exemption,you should
become subject to the Worker's Compcuntion previsions of the Labor Code,you must
�z forthwith comply with each provisions or Nis permitshall Waccrual mvnked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is comuuction lending agency for the performance or
E the work for which this permit 1,issued(Sec.3097.Civ.C.)
:,J A Lender's Name
z lender's Address
J Q I certify that 1 have read this application and state that the above information is
D, correct.I agree to comply with all City mtl county ordinances and sum laws relatingtu
pU building construction,and hereby authorise representatives of Nis city to enter upon the
abovomcntioncd property for iTKCLion pmpoae}.,
F 0. (we)agree to save 'aJemnify,ard G
City of Cupertino against I
h liabilities,jud6mems,c ande anu, y accmc against sold City /r
fJ `,C in comequcncc of th gardm f this m 1
"" APPLICANT ERST ITH ALL NON-POINT Issued by: Date
SOURCE
Re-roofs
are f ticanUComrasuo Dau
HAZARDOdL&A3MRIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant stone or handle hvudou caudal
As fined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safmy
A 'cctY;25532(a)? No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rotor building occupant u.a equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvamous air conmminanu As reined by the Bay Area Air Quality Management
District? all new materials for inspection.
❑Yes �Nu
(have'ad on her duua ma rel yvimmcnu under Chapter 6.95 of the Glilnr
nice Health&SafayQal,Ec'Onn. 5 5533and 25534.1 undc.undthwiftletailding
Jces n t currcml 1i •'s em; 1 rs y responsibility u notify the mcupant of the
meal cnuw mus m or r c F.CenIDcate mea SignatureofApplicant Date
All roof coverings to be Class "B" or better
Own m orirud agent 4Z
Date
CITY OF CUPERTINO 3l
REPIPE/SEWERS/MAIN SERVICE ` J
CITY O
CUPEkTINO PERMIT APPLICATION FORM
APN# 122,ce - 4-2-) " v �� Date:/� �U ' 63
Building Address:
Owner's Name: ho e#:
Contractor: P one: License #:
Contact: - P one: Cupertino Business License#:
,-� SII- G�z
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
COn ►-G - t I �✓ S�-�vi
Residential Commercial ❑
Cost of Pre ct: �bOO
Qty. if/
APPliq51 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 "
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