03080131 (2) CITY OF CUPERTINO '* �rwarp :k
,..xRNOe`i RMAI.aTIYOixN '
BUILDING DIVISIONPRMIT ..... .:;
OUII,DING ADDRESS: AAAA—DRAIN PATROL PERMIT NO 03 O 80131
r
OWNE•R'SNAME: 1.101 S 7TH ST #1 PERMIT LSSH!DATE
NE: SANITARY 9 CONTROL N0.
(408) 989-6005
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
±00 LICENSED CONTRACTOR'S DECLARATION lob Description w 1 hereby affum that 1 am Iittnaed under previsions of Chapter 9(commencing P
�i withSession]gllnuf Diviaion3of Jin u'"mand Professium Cale.and mylicenu is FINALG®
i�a men come «_ 2 WATER MAIN LINE (COPPER)
3 Liccnac CI mc.N
iF ale HITEC99ECLARATI N - AA 2.7 2003
I W< I understand y plan shall W useas public records
)6U
.O1 Licensed Professional
3 OWNER-BUILDER mDECLARATION BUILDING
<I 1 ...,air
affirm thin 11. exempt from 1W Conveners License Law rte the
m following mann.Permit
t 703 1.5,Business and Professions Code:Any city s county
which itsissuance.
requires a pctmit In construct.tithe alter.Improve.Jemrrait t fi repair ed structure
'Lii prionoiu issuance.olso rtyuims the apPlicam for such permit to file aaigneJ summcm
cs< that he is licensed pursuanttothe previsions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
E (commencing with Section 700)of Division 3 of the Business and Proressimu Code)or
1 $ Nat he is exempt tnciefmm and the basis for de,alleged exemption.Any violation of 31628050 . 00
Section 7031.5 by any applicant reir a pamord, bj.w Ne applicant so a civil pcmilty of APN Number Occupancy Type
not team than five hundred della.(5500).
❑I,as owner of the property.or my employees with wages az their sole compensation. T❑77
will do the work.and the structure is not intended or offered for sale(Sec.7W,Business — §b gTA} ect100S
and any h Wild.Code:The domLiccnu Law does not apply m an owner is 2 02 — UNDERFLOOR PLUMBING
andproPin who ns Code:TheContractorsunproved;thercon.and who dmuuch work himulf oan own h his
own employer.provided that such improwmenu and not intended aro@rW formle.If. 301 — ROUGH PLUMBING
bawewq Ne Wilding or improvement os said within ore year of completion,Ne owner.
bund.,will have the burden of proving that M did not Wild or improve for puryom of 3 02 — TUB & OR SHOWER
ale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to 502 - FINAL PLUMBING ENERGY
construct me project(Sec.7044,Business and Professions Cade:)The Contractor's Li. 506 — GAS TEST
eenxcLaw does not apply toanowner ofproxiwho Wilds orimproves themon,and
, 507 — FINAL PLUMBING
who Writmets for such projects with a eonaactor(s3 licensepursuant d pursuano the Contractor's
License La .
I sum am.,,under Sec. ,B&PC far this..an
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby effluent under Penalty of pc jury am of the following declarations:
I have and will maintain a Cenincaw of Consent to mlr-insum for Worker's Carrico.
cation,u provided for by Section 37W of the Its Wr Code.for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Workeri Compensation Insurance,as required by Section
371Wof the Labor Code,for the performance of the work for which this Permit is issued.
My Wmkcr�erC-an2m Pensatinnrinsuvoce carrier and Policy mM,�r
mer: SlrlTrC / �yli$'No.: /H�4�'✓
CERTIFICATEOFSATED SFROMWi0.(C E0S6?C�
CTE OFF EM NS FRAN(6MW 5 ✓
(Thu section need not bu completed If the permit is faranc hundmtldollars(SIM)
less.)
1 certify that in the pufurmonce of the work for which this permit is Waited,1 shell not
employ any person in any manner so az to become Subject o the Warkeri Compensation
Laws of Califomia.Dote
Applicant
NOTICE TO APPLICANT:IL after making this Ccniftcaw of Exemption,you should
become subject to the Worker's Comperuttlan provisions of Bin Latour Code,you mus .
.J O forthwith comply with such provisinns or this Permit shall be deemed ranked.
z wyN. CONSTRUCTION LENDING AGENCY
[�. 1 hemby affirm that there is a construction lending agency for the performance of
G'y the work fur which this peon it is issued(Sec.Xxi Civ.C.)
0 Lender's Name
= z Ldm1,,'s Address
U 0 1 comfy that I haw mad this application and sate mat me awn information is -
IL (~ correct,1 agree to comply with all city and countyordinances and auto laws misting to
OU building construction,and hereby authorize mpresenutives of this city to enter upon the
tk1 ahow-mcntioned property for inspection Pulp..&
y (We)agree to new.indemnify and keep ham less the City of Cupcnino against
py liabilines.judgmenu.coau and expense which may in any way accrue against midCity
U in chosen ...of to grunting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONP INT Issued by: Dat
SOU EGU IONS.
Re-roofs
I amrc 0,ApplicanUContractor m
HAZARDOUS MATERIALS DISCLOSURE Type of RooF
Will me applicant or forum iId. mcupam note or noodle ha oats material _
az defined by me Cupertino Mun'ipel Code.
CbaPur 9.11,and tnc Health and Safety '
Code.Section 25531(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Y
Will me applicant ar rule building occupant use cyuipmem orJcvice which If a roof is installed without first obtaining an inspection,I agree to remove
dl harardous air corruNomm'a dcfncd nyth.Bay Arca Air Quality Management all new materials for inspection.
trier?
❑Yes �No
I have mad the Muni materials requirements under Chapter 6.95 of the Califory
ria Health&SsfctyCodc,Sceduns 25505.25533 and 25534.I understand Nm ifths building
Joos not curmntlyr,tam a¢nam,that it is my mapueibw amity ity thea am,of are
mymm ani maalWmePdae«. aanmar.Cefdhceteofoccapan Signature of Applicant Date
ZS
O croraumhhriraJapcmate All roof coverings to be Class "B" or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE Q 3 J 10 � 31
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# O Date: n 2
Building Address: �J
o , Po R AL Al/F-
Owner's Name: Phone#:
-111 (tJ.9/V ?-
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
IKL Sar -M- 608-22
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description:
Residential Commercial ❑
Cost of Project: o0
200.—
Qty. if
A li Fee ID Fee Description Fee Group
PPERMTI'FEE 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 Sewa a Disposal PLUMBING
BUSLIC Business License BUILDING