03110066 (2) CI'T'Y OF CUPERTINO C,a "'s• �' e "`' <
BUILDING DIVISIONPER MIT NTRACTQR INFORMATION
BUILDINGADDRESS: AAAA-DRAIN ' PATROL PERMIT N003110066
lOS71 RAMPART AV
'-NER'S NAME: 1701 S 7TH ST #1 PERMIT ISSUE DATE
AKAHIRA SAKAI 11/13/2003
PTIONE: (408) 989-6005 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECf PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION'
1 I hereby from that I am Iihanud under pr visions of Chapter 9(commencing Job Description
,� with Section](gXl sf Di inion Sof the Businu, fusion'C do A ra,liccnsris
Ad
0�)ffee 2� b/r NEW SERVICE LINE FINALE®
Z License Clown v!� Lic.
/_ TS DRIITI
q ) ARCHITECTS TION _ NOV 2 4 2003
E 3 U 1 ussyfgYygyyJaa am�l,�tMted as.pu m/¢yr `I�L�
a s_�=c.
e o: Licensed Pmfesmonal j Al■w=
� S OWNER MatIamBUILDERDECLARATION 'BUILDING
<S I hereby.(Grin thin 1 1. exempt from Na Contractor's Co :License Low far the _
-D D following reason.(Section)0]1.5,Business and Professions Code:Any city or county
S$ which requires a permit m Cnnsouct,alter,improve,demolish,or repair any structure $2500
_ZT
poor its issuance,also requires the applicant for such permit file a signed Statement
that he he is licensed pursuant m the Provisions Of to Contracture License Law(Chapter 9 Sq.Ft. Floor Area Valuation -
a+t-D (commencing wi th Section]g10)Of Division 3 of the B usincas and Professions Codc)Lir -
Net he is exempt themfrom and Ne basis for had alleged exemption.Any violation of 3692 6047 . 0 0
Section)031.5 by any applicant for a Permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred dollars($500).
❑ I,AS owner of the property,or my employees with wages as their sole compensation,
will do to work,and Ne structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Convector's License Law docs not apply to an owner of Required Inspections
property who builds or improves Mention,and who does such work himself or through his
own employees,provided thin such improvement are not intended or offered far ssleJf,
however,the building or improvement is sold within one year of completion,Ne ownao-
builder will have the burden of proving Nat he did not Wild at improve for purpose of
We.). _ -
D I.as owner of the property,am exclusively convecting with licensed contractors la
construct the PMjeCt(Sec.7044,Business and Professions Cade:)The Contractors Li-
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a cormactor(q licensed pursuant to the Contractor's
License Law. -
❑ l am exempt under Sec. ,B&P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the fallowing decimations:
Fl I have and will maintain a Certificate of Consent to self-insure for Workers Camped- -
salion,u provided for by Section 3700 drde Labor Code,for the performance of the
work for which this Permit is issued. .
1 have and will maintain Worker's Compensminn Insurance,AS inquired by Section
3]00 of de labor Code,for the performance of the work far which this permit is issued.
My WO ker'sl epmy/p�g-solir II,uAu�renea smoderend Policy he am:^
r. /!,/✓ /`vr'I/ Policy
CERTIFICATE OF EXEMPr10NF WORKERS'
COMPENSATIONINSd ANCE
(This Section need not becompleted if the Permit is for one hundred doilam($100)
or less.) -
1 certify Nut in the perfmmarec of the work for which this Permit is issued,I shall not
employ any Person in any manner an u At become subject to the Workers'Compematinn
Laws of California.Data
Applicant -
NOTICE TO APPLICANT:IL after making this Cempeale of Exemption,you shou5
become subject to the Workers Com penseiion previsions of the labor Code,you mum
J O forthwith comply with such movisinns or this Permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
j-t Ihereby affirm Nat dere is a construction lending agency for the Performance of
the work far which this permit is issued(Sec.309),Civ.C.)
:g1 im Lender's Name
=Z Lender's Address
J Q I hardly Net I have read this application and sixth that the above information is -
W t.. Some,.l agree to comply with all city and county oNinances and sok laws relating to
C U building convection,and hereby autborim representatives of this city to enter upon the
W ahovc-mcrumned property for inspection proposes.
gy (Wc)agree to save,indemnify and keep harmless the City of Caforlino against
T� liabilities,judgments,costs and expenses which may in any way accrue against said City
U t,7 in consequence of the granting of Ihis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL�NON-POINT Issued by: Date
SOU CE ECU I "q^A
Sib rcol'Applica UContracmr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future building Occupant tore or handle hazardous material
AS defined by the Cupertino Municipal Code,Chapter 9.12,and the Heald and Safety
Jc,Section 25532(a)?
C]Year Nu All roofs shall be inspected prior to any roofing material being installed.
Will Ne,applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove '
emit hazardous air contaminants defined by de Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nn
1 have read do hanadous mmerials requirements under Chapter 6.95 of de Califor-
ma He ild&Safety Code,Sections 25505,25533 and 25534.1 undersand thin if Ne building
dins net currently have a tenant.Nat it is my respond hility m notify the Occup rix of de _
requirements which must W m tiar m issuance or a cemreatc9 panty. Signature of Applicant Date
(� - All roof coverings to be Class"B" or better
ncr or auNarizcdacnt Oat
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
D rlP,fiM �� GAJ ��i l��a
Owner's Name: Phone#:
A fes / &YJLr Z--,� f- )
Contractor: Phone: License#:
N' AWL- 1-0901--968 -22 2/ K'
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description: ,/�G�
I
Residential C Commercial ❑
Cost of Project:
J �
Qty
A a 1 Fee ID Fee Description Fee Group
PPERMTTFEE Pluii�bing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
13 7(f