05040154 (2) CITY OF CUPERTINO + r,
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BUILDING DIVISION PERMIT R INFOAMMA.T,
BUILDINGADDRESS; PERMITNO,
CUPERTINO PLUMBING 05040154
t?yNA PERMITL'SUEDATB
NE:—'—..,-- SANITARY OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MRCH
0 0
o LICENSED CONTRACTOR'S DECLARATION Job Des
1 It ion 0(affirm Dintoivision
I am licensed i nss and Profess of s Code, 9(commencing FINAL
/�1®
a� wiahSmtl.n]gk0 of Dlvition Sof NC Business and Professions Code,and myliccnse is fes`_
In full tone end effect.
S Lietate Lle.g >✓Z`ryo5' REPIPE/WATER SERVICE
Data Zi. Contractor�Lap/_y��F /
AR ATIOK N
'� lundcn J u uNic zecnr _� �`� ZOOJ
i
Lwense a BUIL
11
OWNER ILOE ons sho RAlach ®'p ■
f I hereby efOnn Nn I em ea rum tiro LRATIm0r,License law for rhe N
DO following noon.(Section 703 1.5,Business and Profession,Code:Any city or County
$K which requires a permit In convect,altar.Improve,demullsh,or repair any structure
Fa�^ prior In its Issuance,also require,the applicant for such permll to file signed statement
gggg�gy}C'� aNrWe I,IImnxeJ punuanumhe rmvisloa of the Conlrmreri License Law(CharlcrY Sq.Ft. Floor Area Valuat
dla (commnncingwhh SUllon70f10)of Divulon3nftho Busin and Profeuian Cala)dr
3 Nath Is exempt therefrom and she books for the alleged evmpdon.Any violation of
Section 7031.5 by any applicant for a pentb aubjecu the applicant o a civil penally ofOGen P y Tyle
not mare N '�an On hundred dollen(5500). 3 5VRb O 0 8nC ']
❑1,As owner of the property,m my employca wide wages as Heir wk compensation,
will do the woh,and the amort is not intended or offend for aab(Sec.7044,Business Required Inspections
and Professions Codes The Contnemh Lianas law data ter apply m an ewnm of q P
property who builds.harrows demon.and who does such work himself or through his
own employees,provided that uch Improvements aze not Intended m offered for ale.If.
however,she building or Improvement Is sold within on year of completion.dta owner.
bull@r will have the burden of proving thus k did oat Wild m Improve for purpose of
uk.).
❑1,as owner of the property.am exclusively contracting with licensed cm morins In
cousowt the project(Sec.7144,Business and Professions Code)The Contractor's L6
mrue law does not apply to an owner of property who builds or improv domon,and
who contractsOutwit pmjecu with a contractor(s)licensed pursuant m the Conu clor',
License law.
❑1 sus exempt under Sm. ,B&P C farthis mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury arc of the following declantiotu:
1 have and will maintain a Cenifcam of Consent to selfdnsuce for Wmices Compote
don,As provided for by Section 3700 of the Labor Code,for the perfafmance of the
war for which this permit is issued.ve end will maintain Workefe Compensation Insurance,As resulted by Section
3700.(Ibe Labor Cade,for the performance of tis weak for which this permit is indent.
My WorkeY Cmmrenu0o rounnct cartiu and Policy number eze:
Cartier: Gt Policy No.: C' C✓
CERTIFI At OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section sued nut becompload true,permit la foram hundred emilan(S100)
or less.)
1 cenlfy that in the perfmmanm of the work for which this permit is Issued.I shall am
employ any person in any reamerm As or hecome subject la the Worlcri CamrcooNon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become whjml to the Worker',Compenadon provision.of the Labor Code,you must
vJO forthwith comply with such provisian,or this permit shall M deemed revoked.
�y CONSTRUCTION LENDING AGENCY
(~ Ihereby affirm that there Is connrmtinn lending agemy for the performance of
C4 the work for which this permit is issued(Sec.3097,Civ.C.)
W�Q Landcr'a Nanta
Z)z larder's Andress
V Q 1 certify that 1 how reed this application ad rote that the show Information Is
IL r". Correa.1 egne to comply with all city and county ordinance,and sure laws miming to
O building construction.and hereby authorize representa0ves of this city to enter upon the
W ahovomenuoned property for thlrecthan Pugmaeg
(We)agree to use.Indemnify and kwp harmless the City of Cupertino Against
T0.q Ilabllides,judgmenla,cosuadexpen,e.which ayI wayacerueagaioorabl Clty
(„)7 in canaegmnce of the mag q1+M.4.11.
Fl APPLICANT DTA tl5 AND MPLY WITH ALL NON-POINT Issued by: Date
SOURCaR
u.�r Re-roofs
Sig u oData
HAZARDOU kPOR,
ALS DISCLOSURE Type of Roof
Wil oipplicant or future Wilding occuponutore Or handle haallous material
As defused by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safely
Cole,sce,0023332(x)7 p� All roofs shall be inspected prior to any roofing material being installed.
❑Yes �"
will,the apPnoan or future building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
MIII h5mmi air c.nnmlanta oo defined by the Bey Area Air Quality Management all new materials for inspection.
onet? � /�
❑Yes �Nu
lheve used the heardn etenehnyuinmtnts under Chapter .G95of the Califon
ria Health&SafclyCo m25315. 533 25534,111 ntmddraflhe building
docs nal central h an that It feasibility or nobly the mcuPml of the
tequlnmtnn I I aura cruunc,morfkmpamy. Signature of Applicant Date
Own or oriad agent D� All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
fSTYOF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT#
575 APPY WA4 os Oyu' I s�
OWNER'S NAME: 4ISTY f 'L-)AVC'L-)AVPHONE # 40Y, 2Sz 9 Ll s�
GENERAL CONTRACTOR c, ih FAX # p
I am not using any subcontractors: y 2
Signature Date
Please check applicable subcontractors ancTcomplete thefollowing 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile -�
er/ act ature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
if• ZSOS_
Building Address: A /5no Wa
tl
Owner's Name: Phone #:
At e yob
Contractor- Phone: License #:
yob 253 o(01 b &2 L4
Contact: Phone:yob Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ PluraKcl
Job Description: - J
Residential 9j ommercial ❑ t
Cost of Project:a��G _
Qty. if
Applic4ble Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING j
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
i