03060139 (2) CITY OF CUPERTINO
BUILDING DIVISION PI✓RMIT �CONTRACT(1R INFORM AT ION
k BUILDING ADDRESS: PERMITNO03060139
OWNER'S NA61E: PERMIT ISSUE DATE
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
✓•Op LICENSED CONTRACTOR'S DECLARATION Job Description
�u I Mnby affirm IMI 1 am licensed under provisions of CMPter 9(commencing
¢ with Scclion ) (Division Sof NC Busine ll,nprP fcssiona Cndc.and mylicenx is ��� 14.r Nwem
< in mum [., m C6 /9 ?T REPIPE
Liccnx Clazs - Lie.N '
a Dole .o eenlnele CONTRACTOR: C.W. BI CKHAM p 2 2003
ARCHITECPS OICIMATION JUL
u� 1 unders d my plans shall M used a public r emOi
)yu
s a Licensed Professional 1, ��k++(
g I OWNER-BUILDER DECLARATION B�/'LQ'Itl�s
2<2 1 hereby affirm that I am exempt fmm the Contractor's License Law for the
02 following reason.(Section 70713,Business and Professions Code:Any city or county
5$ which requires a permit to construct,after,improve,demolish.or repair any suuctom
poor to its issuance,also requires the applicant fors.ch Permit o fle a signed statement
r< the,he is licensed pursuant 1.ftProvisions ofthe Cmunio r'.U.nmlaw(Chapter9 Sq. Ft. Floor Area Valuat"600
I-� (commencing with section 70M)of Division J of the B usineu and Professions Coda)or
that he is exempt Ncmflom and the buts for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a Final,subjects the applicant a civil penalty of 3WN4gkMer00 Occupancy Type
not mon Nan five hundred dollar,(1500).
(]I,u owner of the property,or my employee&with wages u their orale compensation,
will do the work,and theawclum is not Intended or offend for sale 7094,Business RR �{ I
lls
and Professions Code:The Con.actots License law docs not apply to an owner of 202 2 - UNDER
P1,M) sNG
property who builds or improves theme.and who deessuch work himxlfor through his VVKh' LlJMk311V
own employ=,provided that such improvements tie not intended oro0ehd formic.If. 301 - ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or Improv for purpose of 502 - F I NAL PLUMBING ENERGY
"l`')' 507 - FINAL PLUMBING
m 1,a owner of the property,.B exclusivelynuad connecting with:)licensedcontractorsto
cnnstmct the project(Sec.o an Business entl Professions or I The es th Contractor's rad
come law coca not apply b an owner of pmpeny who Wildspurl ant toves thereon,and
who ronoacLL for such projects with a conuacfor(s)licensed pursuant to the Contractor's
License Law.
[:]I am exempt under Sec. ,B It P C for this mason
Owner Dela
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
1 hese and will mai main a Certificate of Consent to self-insure for Workefs Compete
cation,as provided for by Smile.5700 of da labor Code,for how performance of the
wait for which this Permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700of Ne Labor Cafe,for the performance ofthe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number an:
Carrier: Policy No.:
CERTIFICATE OF E UiM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need notal completed Ulhe Permit is forme,hundraddollars(SIM)
of to'L)
I cenify that In the vrofnrmance of the work for which this Permit is issued.P shall not
employany person inany manngf sen ate} t become subject to The Workeri Comjac.mian -
LawsorCalif�OetaGl p Z
APto I
N TO tP LIC :If.after making this Certificate of Eacmption,you should
thematic s.hj=I in the Worker's Compensation provisions of the Ice Wr Code,you must
.JO forthwith comply with such provisions or this pi shall be deemed revoked.
y h CONSTRUCTION LENDING AGENCY
i P hereby elRr
that then its construction Pending agency for the perfurmarec of
C(> the work for which this permit Is issued(Sec.3W7,Ci,C.)
W Leader's Name
z lender's Address
U Q P cattily that I have mad this application and sun,that the above informatiun is
W H correct.I agree t0 comply with all city and county ordinances and show laws heating to
DU building construction,and hereby auNorim mpmenutivcs of Oil City to enter upon the
G ahove-mentioned property for inpection Purposes. 9
(We)agree to save,indemnify and keep harmless the Ci IT of Cupertino against
wh liabilities,judgments.costs and expenses which may in any way accrue against mid City
U in consequence of the ganfing of this Permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURC�gEGU S.
Re-roofs
' gree o De c
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Ctm rel or(Muni building orcupe,Chapter
store orand 11 Health a material
u de0ncd by the Cupertino Municipal Code,Chapter 9.12,and Ibe Health and Safely
Cora,Sectionpvu 25532(ad? N. .. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futon building..pact use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
h hmardous air miumbinants as defined by the Bay Area Air Quality M.ru cmem
strict? all new materials for inspection.
❑Yes CZ11.
I have mad the han thVs materials requirements under Chapter 6.95 of the Cali foo-
ria Hmith&Safcty Co .Sccd.n505,25533end25534.1undcrs uifNc Wilding
doesn��
y ms mihildy w notify the occupant of the
mqua is Ccnlficaw 0f cy� Signature of Applicant Date
Date All roof coverings to be Class "B" or better
F/SEW,ERS
Y OF GUPERTINO
REPIhVIAIN SERVICECUPEI�TINO PE APPICATION FORM
APN# Date: —�3 l b 3
Building Address: oZ
Owner's Name:
.a C
Contractor: k Pticens #:
w ,c ua as - 7G z /y FF (f-3,6
Contac Phone: Cupertino Business License#:
UZZ L
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
r E
Residential Commercial ❑
Cost of Project:
•
Qty. if
A lic 15)b\ Fee ID Fee Description Fee Group
PPERM17rFEE Plumbing Permit Issuance PLUMBING
BPREPIPERe 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
2,
2 q2, �8