05030180 (2) CITY OFCUPERTINO
BUILDING DIVISION PERMITCONTIir1LC"TQR ;NFO(RMATION
BUILDING ADDRESS: SOUTH BAY PLUMBING PERMITNo05030180
e
f{[, OWNER'S NAME: PERMIT ISSUE DATE
C7ARCHITECTIENCINEER:
ONE: SANITARY . OL NO.
BUILDING PERMIT INFO
BLDO ELECT PLUMS MECH
oLICENSEDCONIRACTOR'SDECLARATION7obDescription
1 bereby affirm Nn 1 am detmN under previsions of Chapter 9(commencing
Section 701M))of Division 3 of the Businw and Propfessions Code.and my Ikeomullforce and a 'Of7�5�
a�naecly, co��.ter Q CLEAN-OUT (CURBSIDE & MAINLINE)
Mt FUtilL,4t
ARCH S DECLARATION
'1 understand my plao shall he used u public records
3 u,� Lleemed Pmfcosional
303OWNER-BUIIAER DECLARATION
X I hcmM1y o(nrm that I am exempt from the Contractors Lkenac law for the
p 0 following mason.(Section 7031.5,Business W Pofnsims Cade:Any city or county
$fLi which requires a Permit to contmc.simr.improve.demolish,or Congo any structum
F y prim in its isstrance.also requires dt applicant for such permit o file asigned Comment
�< Nat he is licensed puraant in the Provisions of the Congaree,liceam Law(0tapter 9 Sq.Ft.Floor Area Valuat on
(commencing with Sectbm7000)of Division 3 of the Business and Profcasions Com)or
Net he b aampt Lemefrem and the bark fee the alleged eampdaa My violation of
Section 70313 by airy,applicant for a permit mbjecu rite applicant he•civil Penalty of 3 5 �10 0 Occupancy Type
not mom Nan five hundred dollen(S500).
❑1,a owner of die property.or my employees with wags so their note compemmion,
will do the work and the structure Isnot intended of offend for sage(Sm.7044,Business Required Inspections
and Prlywh ore Cade:The om trerem.License law!ore not apply ir rt owner of q
psopenywho Wilds mimprowch Improvements;
mdwho amasucb worse Mm mothered
his
ownem.due
Net such impmwmano sec not amended mo@rnd fm oak.if.
however,Ne building or Improvement is halt a did one year o(impoo tiara.the owner-
builder wi0 bow the burden of proving that ng did oat build m Improve for purpose of
ales). 3
❑1.as mvner,of the property,am eulmivedy canmnoting with llcemad conuacNn N /
construct Ne pmjen(Bee.ad an weer of andProfessions,who
Code:)The Cmtr¢urs U.
and,cents law coca not apply m ts owner of property who Wilds or improves t,emon,and /
who contracts for such pmjecu with aconuacmr(o)licensed pursuant mthe Canuactoh
Licmm Law.
❑iamexemptunderSec. ,B&PCfm Nurexdsm,
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby a(n, under penalty of perjury arc of tis following declarations:
I have and will mvnuin a CeNBcste of Conant to calf-insure for WorYerCCompen-
satian,u provided for by Secdan 3700 of Out laser Code,for Ne Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a required by Scmian
3700 of Ne Labor Code,fm due performance of the wort for which this permit is issued.
My Warke/ra1Com mad bosun ,nim and Policy number am: LQ,
Cenitr.; �- 'T Policy No.:'71�"OOI D✓oO
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This acdmn need Out becampletW If tie,Permit ufmonehundred dollars(5100)
or less.)
I certify that in the performance of the work for which this Permit Is issued.I shall not
employ anypsoon in my manmerso at in become subject In the Worken Compena0on
Lowe of Callfomh.Date
ApplWnt
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Om labor Code,you must
.J O forthwith comply with such provisions or this Permit shall w dcemnd revoked.
z CONSTRUCTION LENDING AGENCY
[-n4 1herebyellirm Haft.is a contraction lending agency fm the performance of
pG> the work for which this permit Is bound(Sec.3097,Civ.C.)
It,Q Lenders Name
Z Lenders Mdecu
U0 I ceNfy No I haw mad this pplication ad rete that the show:information is
W, coma I agme to comply with all city and county ondinarms and sum[am miming to .
0 Wilding construction,and bemby audmris Mpoclnutiws of this city ucnw upon de
W above-mundane!properly for inspection purpose&
(We)agree to save,indemnify and keep bumless Let City of Cupertino against
En IiebilR
gmenu,case and expenses which may In anyway attmt agsinatheie City
U7 in ee ofthennting NDERSTANDS AND I COM WITH ALL NON-POINT Issued by: Date
ULATIONS.
Re-roofs
Sign ureo Applicant/- trmrer Dam
H RDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Aurum building occupant amus orhandle haanlous material
as defined by Lee Cupertino Municipal Cade.Chapter 9.13,and the Hand and Safety
code.Scmian zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed,
❑Yes FRWo
Will the applicmt or fuure building occupant use,equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haardnm air conbminanu u defined by the Bey Area Air Quality Management all new materials for inspection.
bidet?
❑Yrs on
Ihaverecd theh rdmsm wdabrequiremanuunder .Chapter6.95ofLe Califor.
malialth afmyCode.S=6=2550S,25533am12553a.l understand Leaving building
dam not n0y haw a tenon t a MY respomlulity u notify f mcuPat of t,c
rcyui to whicnmutbemetprior WWaamtancenifiatearOcapanty. Signature of Applicant Date
ow rormthoriec agent pare All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY F Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: 10355 PG•�o r ,(�I�4r, .n ®I��C , PERMIT # 0-S-0 3 v
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: 3 - 17- 05--,
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
qF Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Own /Contractor Signature Date
wo
REPI E/SEWE S/MAIN SERVICE
CUPCITY OF CUPERTINO
ERTINO PERMIT APPLICATION FORM
APN # 3c7-7 v Z 05-2 Date:
Building Address:
Owner's Name: Ad Phone#:
ex
Con trac or: Phone: License#:
2" qo8-37o -35 5 Ilq
Contact: Phone: Cupertino Business License#:
('e ( �ob OQ- 35a-�'95a
Building PerrrHt Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project: u 6a
•
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbin.g Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING .
BPFIXTURE Pb] . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
2J' �
CITY OF CUPERTINO �" 'a
BUILDING DIVISION PERMIT ; "sON'SIG
BUILDING ADDRESS: PERMIT N%4020108
%4O2O1OS
Z394 PALIQ VISTA RD
NEWS NAME: PERMIT ISSUE DATE
n
E; SANITARY 2 CONTROL NO.
ARCHITECftENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTORS DECLARAnON Job Description
�j I hereby M.Out I am licensed ander providns oof Chirac,9(commerve.1
with Section 7")of Division Sof the Business ad Profeadoni Code.and my license is
^ in fall sora and effect.
5gz Licc.Class Us.e RELOCATE PATIO DR. ADD WINDOW IN FAMILY RM
nDau Contractor
�i ARCHr1ECPS DECLARATION
iy 1 understand my plan WWI he used u public record,
36
3� PmfeuioMl
OWNER-BUILDER axe DER DECLARATION
it 0 y ,
hereby.(Rata than 11. exempt(ruse the Convenors :Any c 4w for the
it O o following mama.(Section 7031.5.BMineas and ve.de funs Cod,:Any city or county
$P`i which rcqulma a permit to construct.alae Improve,dcmalah.or repair any anrecmre
�,Z Sat prior m is i eased pursuant
to
the the applicant fot such permit to ice stlmd Cha ter 9
< OutheidacnedpurmentmthepmviAonnflMConuuessanccnmlaw(Chap¢r9 Sq.Ft.Floor Area Valuation
FC$ (cat ho Is ag with Section TODD)00 the
Division r of the business ne ad ProfeuioM Cede)or
3� Inset he a e¢mPt Wemfmm and Oe baa for W alleged cumpdan.Any violation of
Section 7071.7 by any applicant for a permit Subjects the applicant o a civil penalty of 3 5VRN**g0 O Occupancy Type
not mom Oust fin hundred dollars($7(10).
❑I,u owner of rhe pmpeny,m my employm with wgu u their ole ccmpenuOo",
will do the work.and the tuunue Is not intended or offered four sale(sea 1044.Business Required Inspections
and Profession Code:The Conmwrl License Law dm e not apply in an owner of q P
property who but Ids or imprMea thereon,and who doeuuch work himself or through his
awn employm,provided that such Improvements art not Intended suffered formic.IL
builders,the building or improvement Is hath a did one Rrt Mc prove for
the use of
builder will nave Ou burden of improvement
Out he did nae you M Improve for puryase of
teak.).
❑1,u owner of the property.am eactuively contracting with licensed contractor In
construct the project(Sec.7044,Business and Profusion Cade:)The Canuaeroes LI-
wnu Law dm not"plypr m um owner of property who builsed p or Mpwwa flabormonContra.red,
who ease Law.(m such projeea with aeonuactor(s)licensed pursuant m the ConumtoM1 j
license Law.
v l am eno ncies .B At P Cfar
'this 1ma"ver J
Owner Oau ,
OR ER SATION DELLA TI •r/ r d p v�
Ihereby affirm under pemlty o pedurry mmof tag declaration: v�
1031,1
law and will munWn aCeNncau of Cement seIFIMurt far WorkeraCampen-
n,m provided for by Section 7100 of the Labor code,for dm performance,of the
car which this permit it Innes
haw reed will mrinain Warterst CompensaOon Insurmne,u requirtd by Sudan
of the LabeCede,for dse peAormarce of Ne work farwhich this permit a issned.Workers Compositions Insunncn carrier and Poliry number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE -
(ITasemiw need not bacanplecd If Oe,permit is(mnnehundseddoRara(SIOD)
or leu)
I cenify that in the performance of the work for which this permit B Issued,I Nall ne,
employ anypermn in my mannerm u in become subject to are,W°rken'Compe Sidon
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,afar making this Cc tincate of Emmption,you should
become subject in the Workers Compensation pmvaion,of the Labor Code,you must
.J O fothwith comply with such provision or this permit Nall bo deemed ranked.
Z ti CONSfI
fRUCON LENDING AGENCY
(-r I hereby affirm that them is construction lending agency for the performance of
CG 7 the work for which this permit is Wood(Sec.7097,Civ.C.)
aQ Landers Name
D z LendersAdmu
V Q . 1 certify that 1 ban red this appllcithm and rete that the show Wormdun ie
D. concha.l agreetr to comply with all cityuqu and county ntoo mor and sora laver misting e
aboveng construction,and forherebyIre authodve rtpmsenutivu of this shy to coat upon the
W shove-mentioned property for inspedan ceep bibulous
n. (We,)agree to caw,indemnifystreams
and which
may
I the y se of mCupertino against
Uh I.consequnce of the In and ea penscawhtch may Inany way acme against told City y�
U4 7 APPLnsegA nceUrthERSTANDSnterior,of thie Permit.WILL COMPLY WILL NON-POINT Issued by: Date ✓!.�/
tom- URGE TIONS /
kedYl2 1 Re-roofs
Sign re ndConRDO a .
HAZARDOUS MA IALS DISCLOSURE Type of Roof
WIII y the
Cupen im fMuni building e.occupantChapter
alone.,ludhe Health an material
u dunned by Om Cupenlno Municipal Code.Chapter 9.13,teed the Health reed Safety
Cade.Sudan 37573(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yat Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t Imardau.I,caauminnss u&fl.d by the Bay Am Air Quality Management all new materials for inspection.
D st icIT
❑Yat 2mo
Ihaveroad dmhuud mar5rid5533Wen534.1ox rChaptar 6.95.f udermaftIfhe Wilding
ata Hplthk SalZd
he..Swdm 37507.3757)anW2d5N.1mdcmmdthstllthebu06ng
dm trot eunenhew• L It a mY respominility b Mdfy Ne occupant of do
q"""sawmuss toWamwara etr ' ° Signature of Applicant Date
°rte .ant .to All roof coverings to be Class"B"or better