05030329 (2) CITY OF CUPERTINO ».r .a
BUILDING DIVISION PERMIT C,ONTItAC�'TORINFRATION ,
BUILDING ADDRESS: PERMIT NO.
BAY AREA REPIPES 05030329
OW NER'S NAME: PERMIT ISSUE DATE
10NE:
SANITARYqtFOL NO.
ARCHTIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0o
I LICENSED CONTRACT'OR'S DECLARATION Job Description
u 1 hm Nem mu
ereby affira,I licensed under pvisioof Chapter 9(commencing p
wiOScaion70(10)of Division3ofN Businaaa .fcssinu Calc. dmyliccosais
fu 11 forte and IF
�'? uan c1u ^3� Le.N REPIPE, WATERHEATER AND WATERSERVICE
n s-� Date Con
ARCHITECTS IEC DECD 1
I undcnunJ my plana still W used As public rtcnrds
JyU
3 Liucnxd Professional
@ 3 tat I am exempt fr DECLARATION
d y I hereby.(Sinn c m 1 em exempt from tic Contractor's Co License law for the
O yO
which
reason.(Section 731.5,Business and Preere.de iuu Cade:Any city or county
k m W which rt4uiressu n e.alio to comquires ucr,alter,improve.h Permit ri repair ed statement FZT
prior bits issuance.also xgYIre3 Ne appliWl,for such perl111I lO BICaiigned inNmen(
< Nathcislicensed pursuant tothe provisions oftcComncler'sUccnxLaw(Chapter 9 Sq. Ft. Floor Area Valual on
QFC (commencing wit Section]000)of Division 3 or the Business and Pmfcsimm Code)or
A. $ Nat he u exempt,hemfmm and dx huts for the alleged csempdon.Any violation of '1
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number �t ( Occupancy Type
not mese Nan Is.hundred dollars(35001. `(J 1�
❑I.u owner of the property.or my employees with wages u their sole compenudon, 1 }, \
will doteworc.od Nesuuctute is not intandcd Or offered forage(Sec. Business ' t' t•.
IIRe aired-Ij ns ecUons
and emplo,c s,provid The t such i ori Ciente Law does not apply er an owner of �\ !JJ ,
propertywho eCutri The C.A mean.Limmewth.cloes LawOhwork himself anOwne his !. 11!/
awn cmploycrs,provided tot such improvements art not interWcd proffered Tarsale.if, s )
bull& Ne building burden
ovementis athediinot year ofmprovefrNe
builder will have d¢burden of proving Nat he did not Wild or improve far purpose of
ole.).
❑1,AS owner of Nc propcny..B exclusively contractingfesswith )licensed contractors to �-
ceme La Ne project(Sec.toad.Guiness end nywho Wilds
Cade:)The Castration's tad
ttue Taw dors not apply to to owner of proper(who Wilds or improves Nexon,end
who c for such projccu with a convactor(s)licensed pursuant to the Contractors
ee Law.Law.
❑Tun exempt under Sec. ,BkPC for Nis rtuon
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declandan:
1 haw and will maintain ACeniOcate of Conant to self-insum for Wortrr'sCompen-
737W
ion,u provided for by Stmmo 3]00 of tic labor Cade.fa tic Performance of the
h for which Nis permit is issued.
1 have and will maintain Worker's Compensation Inwnna,u required by Section
of Ne labor Code,for Ne performance of Ne work for which Nis Pe �issPed.
y Worlo,CJtmppuatignirtwn�e Wrier and Policy number an:rrier. '.-/i•I/O's�'ItYCn-Iter aI CS� Polity No.: Zyd 7
CERTIFICATE OF EXEMPTION MOM WORE
COMPENSATION INSURANCE
(Thu sectim recd net W completed if the permit is furore hundmddollan(SIM)
or kss.)
I artily,Las in the performance of tic work for which this Permit is issued.1 shall not
employ any peon to Any manna an As to Wo me wbjem n tic Workcrs'ComfAmeadon
Taws of Ca ifomis Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenioate of Exemption,you should
become subject,o Ne Worker's Compensation provisions of Nc labor Code,you mus,
.Jz forNwit comply wit such nowisinm or On permit shall W damcd nvokcd.
Z O CONSTRUCTION LENDING AGENCY
E-t4 l hereby Affirm,Om tem is a construction lending agency the Performance of
LYi> to work for which this permit is issued(Sec.7041,Civ.C.)
zz Undme
er's Na
= Lcndcr's Address
V Q 1 certify than 1 have rad Nis."Immum And.m n that d e item information is
II. corrtcL 1 agree to Comply wit All city and county ordinances and Aute laws miming in
0 Wilding construction,and hereby auderim mpmscnu,iws or Nis city to enter upon Ne
Y'G .hove-ms,judg dproperty for inspection puryuxx
(We).gra to saw,indemnify d kap hermits On City of Cupertino against
j-.
(ZIz in
of he costs and cx which may in any way accrue against aid City
tJ z A APPLICANT
a(Ncgnnting/f ND'r L
^ APPLICANT ER A ` AND WILL COMPLY WITH A L NON-lljOINT Issued by: Date
SOU
st �ueanuc nuxmr rDaa Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tW Applicant or future building occupant mom or handle hanardou m.mrial
As defined by the Cupenim Municipal Code.Chapter 9.13,and the Health and Safety
,dML(uxJO.Seedon 3ss33ea)y All roofs shall be inspected prior to any roofing material being installed.
❑Yu ON.
Will the applicant or future Wilding use equipment m avian which If a roof is installed witho t first obtaining an inspection,I agree to remove
haxardr ix air conuminants u defined by the Bay Area Air Quality Management all new materials for in ection.
71t
wict?❑Yes ❑NoI have mad the banrdms mate ria vixmenuxenonChAucr6.95oftcCalrM-
HealN6SafetyCoo.Socdom35 ,35533 am13553 .l narurd tm ifthe Wilding
s netcurend aw A tenanL a t u my nsponsihilitY m nm(y,W oecuPAM Or the
uimmenL ,uissuanaof.cerdf¢eeofGccupancy. SI atureofApplicant Date
ners at n .sen, ^cost. All roof coverings to be Class"B"or better
• r Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT # O5-D303L.�
nJ she ceZn ,
OWNER'S NAME: ; VIVV% PHONE # i
GENERAL CONTRA OR: FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Ah Linoleum/ Wood
qW Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tilea�z—
//Pfl,-c� -?/ o 6wner/ Signature Date
- oSo30329
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPER0TINO PERMIT APPLICATION FORM
APN # �3 / O J Dat
31
Building Address: (� /
IO�V D/ i7 rcL Lq,j
Owner's Name: Phone#:
Contr tor: Phone: License#:
K,yttt ?d 3
Contact: II c Phone: Cupertino Business License#:
St) � dlsafa5en o _ oo -7 77
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: n
((,
Residential Commercial ❑
Cost of Proj
Qty. if
FABPSEVYrER ID Fee Description Fee Group
EE Plumbin Permit Issuance PLUMBING
Re i e of Fixtures PLUMBING
E Bld . Permit Fees BUILDING
E Pbl . Fixture PLUMBING
Main Water Service PLUMBING
Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING