04070177 (2) r CITY OF CUPERTINO
BUILDING DIVISION PERMIT I;CONTRACTOR TNFRMATT�ON a
BUILDING ADDRESS: CUPERTINO PLUMBING PERMIT N004070177
OWNER'S NAME: PERMN ISSUE DATE
MAY KOSKI
IFNE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� L 0
jdF LICENSED CONTRACTORS DECons or CON .A y.
5s p 1 hereby affirm that I am lithe Bu under and
Professions
of Chapter 9(commencing AUGJB IJe ion
[M with Section 701N))hfDividon 3of0m Business and Profeufum Code,and lieenu is sss000
infuUfume andeffe. , G2 a-/ U5 COPPER REPIPE
z = Llrenx L Lic g BUILDING
z p Oem Cunlrlcbr f�
7W SDEC TIDN
yt� Iundera dm a u" a
GS Licensed
OWNER-BUILDER C N
ji S I It by aTrm Nn 1 am exempt from the Contracmr's License Law for the
0 0 followin mason.(Section 7031.5,Business and Profeuions Code:Any city or county
$ which tarpons a permit to innWuct,alter,improve,demolish,or repair any swcted snno.
s.Zepoor to its issuance,also requires the applicant for such Permit to rile a signed statement
0 that he is licensed punuBnuothe prvislorunfthe Conuactor'sLiccnmlaw(Chapter 9 Sq. Ft. Floor Area Valuation
a (commencing with Section 7")of Division 3 of the Business and Professions Code)or
that he Is exempt thertfmm and the basis fm flue alleged exemption.Any viDladon of
Section 7031.5 by any applicant far a permit subjects the applicant in a civil Penalty of 3 W N3Quhl7er0 0 Occupancy
not mom than five hundred dollars($500). p y 'Tri
7 pC
❑I,es owner of be pmpeny,m my employees with wages u theb sole eompenudon,
will do thework and umstsuctum is nmintended oraRered formic(Sec.7044,Business Required Inspections
and Professions Cade:The Contracmr's License Law does not apply b an owner of q p
property who builds or improves Nucon,and whodo auchwmkhimulfor Waugh his
own employes,provided that such improvements art not intended oroffered for uln IL
however,the building or improvement is sold within one year of cempleuon.0te mammy
builder will have the burden of proving that he did not build or improve for purpose of
tib.)
❑1.a owmr of the property,am exclusively contracting with licemed.ntio ebes to
construct the project(Sec.7044,Business and Professions Code:)The Conlnebr's Li.
cents law does not apply to an mount of property who builds or imp haves thereon.and,
who contracts for such projects with a conuacter(s)liansed pursuant he the ConuacmYa
License Law.
❑I am exempt under Seo ,B k P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby+Dion under penalty of perjury one of the following declanuons:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compon-
sstian.uprovided far by Smile.3700 of the labor Code,for the performance of the
work for which this permit is issttM.
1 have and will maintain Worker's Compensation Insurance,a required by Section
700 of the labor Code,for the performance of the work forwhich this permit is issued,
My Whittles chmpenaadan Imuran.carton and Policy n��umvvb.er....art:
Cartier..Flr1+C—GUNGI Policybkx:(!:�T 7G6(0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITIS a.tbn need not he completed ifthe Permit is Indian hundred dnllan(5100)
or less.)
I.airy that in the performance of the work far which this permit is issued,1 shall nos
employ any parson in my mmncrm as to become subject m the Workms'Co npcnsathm
Laws of California.Dam
Applicmt
NOTICE TO APPLICANT:IL nfler making this Ocr ificam of Exemption,you should
become subject to the Worker's Compensation provisions of dm labor Code,you must
,JO forthwith comply wilt such Provisions or this permit shall be d.med booked.
Zti CONSTRUCTION LENDING AGENCY
F+� I hereby afrim that then is a compactor lending agency for the performance of
C' the wants fur which this permit Is issued(Sec.3097,Civ.C.)
Qcorrects Name
=z Lender's Address
O 0 1 certify Nat 1 have read this application and sure that the abhor inforadun is
0 U building 1 agree b comply with all city mu county ordinances mu sum Irvnt r Upon
to
0 building construction,only hereby imps aha n representatives of this City to coot upon be
LVLT ahove-menudgm pmpcny for imps n purposat.
fY (We)agues to ears,hour y and p harmless the City of Cupertino against
h Ilabilitlea,judgments,ca an pens hich III an ay III eccagainst aid City
V z mcootsegancc ofth of th' rmi✓
^ APPLICANT U R N ND WI ITN ALL NON-POINT Issued by: Date
SOURCE RE A S cw� P,
7 zg'QL� Re-roofs
Signal of Appl UChntnnor Data
HAZARDOUS MATER CLOSURE Type of Roof
Will applkamrfuwrc building Occupant store or handle hvardous mamael
a defined the Cupanian More
Code.Chapter 9.13,and Be Health and Safety
odc.Se on 35533(.)7 �j All roofs shall be inspected prior to any roofing material being installed.
Yea (4-a
Wi0 the applicant or future building a.upam ata equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit hazardous air contaminants as Jcrined by the Bay Area Air Quality Management all new materials for inspection.
DisuicR
❑Yes COV.
IhacmaJthehoes, yv/amamr9m'q entsunderchaporfi.95ofthc Califor.
nit Hmlth&Sof YC iso 25' ,25533 d25534.1unticomndthalifthe building
e.a note he ¢n thi I ism ihility b hoary the occupmt of the
bquimmen wic p et" sfacenifica� �acy.-_ Signature of Applicant Date
Owns ram nxeJagent pais All roof coverings to be Class "B" or better
aClOF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: e / P vT#7v 7
OWNER'S NAME: / PHONE # Nds 2S3.6t, i o
GENERAL CONTRACTOW Ift11771n FAX # (t/02)2!r3 0Co7 3 L
I am not using any subcontractors: 6 T
SignaDat
Please check applicable subcontrtors and com let o in_ 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 NjeAl
She dock
/Col actor Signature- Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE 2
CUPEkTINO PERMIT APPLICATION FORM
APN # d3 .0 Date:
Building Address: .^��
Owner's Name: ,fin p� S�l -f— Phone �56�
Contractor: �rU��to �0 S License #:r Zy�Qr
Cont;c�0", / Phone. Cupert'no Business License #:
�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: Ii
Residential Commercial ❑
Cost of Project:
•
Qty.
A_ is le Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Perrnit Issuance PLUMBING "
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbla. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
a C) � 3 ,