04110081 (2) CITY OF CUPERTINO
COWRA.C...0�R I ,,(,)K `AV1fj�F
BUILDING DIVISION ,a..- _ PERMIT
.' BUILDING ADDRESS: ' _ -- PERMIT NO0.
, CUPERTINO � PLUMBING 4110081
1EXR99 1N
OWNER'S NAME: - ' PERMIT ISSUE DATE .
ONE: SANITAR I OL NO.
ARCHITECT/ENGINEER - BUILDING PERMIT INFO
BLDG ELECT PLUMB,. MUCH ..
+!p Z `LICENSED CONTRACTORS DECLARATION
m O � I Wren,affirm that 1 am licensed under previsions of Chapter 9(commencing 70b DeSCrlpt]On
- = s
wih Scercmn])(IeDivsion 3aftW Buaina
dRvfcalons Code.end mylicnse is
infull eandefrec
�oo LicnREPr
IPE/WATER SERVICE
JDare
t mreclor '
--
ARCHr1EC1'S DECLAR ION _
1 understand our Plans shell be used as public records - - .. ._. -
'3a� Licensed Professional -
m3 - OWNERBUILDERDECLARATION •"' �� .. .-
I hereby affirm Nat 1 em attempt from the Continuous License Law for the /
p O following 2adan.(Section 7(D I.5,Busimah and PID eadons Cade Any city memory''IRE whichrequires a Permit in construct.atler,.imporn.demolish or repair anystructure,
or;C w prions its issuance,also sequins the applicant forsuch Permiu0 file a signed statemeo
nt
F Natal is licensed Punuent to the Provisions of Oic Comra:mh Lmcnu law(ChePmr9 _ Sq.FC Floor Area .'. alualon .
$ (commencing with Section700MUDivision 3 oflhe Businessand Professions Code)Or r
.. that M is anmpr thorefrom and the basis for.We alleged eaemptlon.Any violation of �T 1v.
Section 7031.5 by airy applicant fora permit subjects the appikcivil
al to a penalty of 3 l� Occupancy Type.' -`
not mom than five hundred dollen(5500). -
1,a owner of the property;or my employees with wages es their sole cempenaatioay
willdo the work and the structure m aitiatended or offered forsale(Sec.70aa,Business' „c -
and limitations Code:The Connectors License Law dors not apply lo an owner of Required Inspections,
enywhobuildsorimpr themon,andwhodoeasuchworkhimeelforthmugh his -. '�'.• ,. ,. „�, „ yam. z�i•";'�
own employees,provided that such improvements are,notimmnded oroDered forsam.If.
however,the building or impmwment is sold within one year of completion,the owner. ..
builder will ban the burden of proving that he did not build or improve for puryose of
sale.).
❑1,as owner of the property,am exclusively coneracling with licensed convectors to
consumer the project(Sec.7W,Business and Prefossimn Cade)The Counselor's Lt -% Iv
coni'law docs not apPly)q a i caner of property who Wilds or improws thereon.and
who contracts for such projects with numaracmr(s)licensed pursuant to the Contractor's
License Law. .-..� _ ..._... ___._..-..-,.�_... ..__._
Ej I.exempt oder Sec. .B k P C for this maeorP -
G`
Owner ' Dem S v
7 KER' MPENS ' DECLARATION
hereby sf ore under n perjury one of the following declarations:
I have and will mMetal.a Cen ricste of Consenta0 self-intim far Workers Compen- ..
ration,as provided far by Sedan 3700 of the labor,Code,far the poolonaaee of the
for which this permit is issued.
an and will maintain Workers Compensation Insurance,at required by Section
of the Labor Codc.for the performance of the work for which this permit is issued.
My WorkQcrt�CoralI pensedon/in-sunn artier and Policynumber art—:
Carrier:(�31�T'e Yf/I Policy No,:' GOG'g-'V
CERTIFICATE OF EXEMPTION FROM WORKERS' _ -_.:,t •`' .a.'.:'A'.. :,r,: ' •^
COMPENSATION INSURANCE - - - - -
(Thlswetion need not W completed lithe Permit is formic hundmddollem(5100)
or loss.)
I unify Not in the performance of the work for which this permit is isvued.I shall not
employ any poison in any manner an as m become subject to tbo Workere Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenifmate of Exemption,You should '^-
become subject to the Worker's Compensation provisions of the Labor Code,you must
.�z forthwith comply with such provisions or this Permit shall W deemed ranked. -
ZO CONSTRUC71ON LENDING AGENCY
I hereby affirm that Were is a consvuctinn lending agency far the Performance of ... -
Ci 7 the work for which this permit is issued(Sec,3097,Ci,C.)
W QLenders Name
gl� z Lenders Address -
t 7 Q _ 1 unify that T have reed this city
an unit
and ane del and
sbovc information is
{[a torten.I agree to comply with all city and coo ty ordinances of and sum laws r upon t 19
V building consuuetion, rt le cby auNorim resenutirrs of this city to enter upon the
W ahova.mondunotl p ray for'Rspedon rpase
gL (We) o seve,iticmnify keep lest the City of Cupertino against
Pyy liabilities,BM(I autooaL}} ndexpcn whit ey many way.cenw.geinstaiiCity
U z in cone den of the br flung of 1 Patti - - G' _
APPLI A UNf T NI)S ND W, BL WITH ALL NON. NT Issued by: Date
SOU E t
(J Re-roofs
I or n sea rer Dam
HAZAR ATERIALSOISCLOSURE Type of Roof
Will the eppfcantor t W pant store or handle haardous material
as dei d by the Cupertino -i poi Code.Chapter 9.12,and the Health and Safety
Cade,section 25532(41 All roofs shall be inspected prior to any roofing material being installed.
Ely. Nu
Will the aPPnan oil N building a spam o equipment or a'uket semen _If a roof is installed without first obtaining an inspection,I agree to remove a
roll haeardnus air coma 'nano a dail db dm Bey Ana Air Quality Management all new materials for inspection.
Coiner?
❑Yrs �.
the mad NevNous i qui ments underCWpter 6.95 of the Califor. �
nI.Has Safctyc ;Sams 5m: 5J3 125534.1raderitead Nmifdte Wilding
duos I urtently are vthal i my sponsibility m notify the occupsnr of the
m re e be 1 r las cef.Cemficamefoccupency` Signature of Applicant Date
r ( ' All roof coverings to be Class "B”or better
Ow rttrilutnxind agoal Dem
A
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
IOCITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
10401 'Prvn�-rG� Lane, 0 L//66 g /
OWNER'S NAME: Pp- )kii n -Lia ";a:IPHONE #(17,0q) I 5' 0S'3'7
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: 11- 15, C-4
Sign Date
Please check applicable subcontractors and
cc
lete e followin 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
44,
Own actor Signature. oil
Date
s
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# ` 3 U`ry Date:
Building Address:
6q�� _p
Owner's Name: Phon #:
::17,)r. $� C-1 g 3
❑tractor: Vl,vl Lh
2S3 � ) Lice se g D
CML
h ne: Cupertino Business License#:
Ml
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: ,
Residential Co ercial ❑
Cost of Project:
•
Qty. i .
c bl Fee ID Fee Description Fee Group
PPERMITFEE --Plumbing Permit Issuance PLUMBING
eb 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 Sewage Disosal, PLUMBING
BUSLIC Business License BUILDING
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