05040052 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT A.CTQR INpORMATIUN
.Y4.,. ,vs
BUILDING ADDRESS: PERMIT N0.
NELSON PLUMBING 05040052
OWNER'S NAME: _ PERMIT ISSUE DATE
ONE: SANITARY OL NO.
ARCHITECOENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
17
OI LICENSED CONTRACTOR'S DECLARATION
1 Weby Nitro Wt 1 am licensed under provinces Of Chapter 9(commencing Job Description
S1
with Section 7000)of Division 3 oflhc Business and Professions Code.and my licensee
in full fares and efrov. U G l7
n z LkenseClas Lk.I REPIPE & WATER MAI)
Dam Conuactorm _
ARCHRE co DECD
I understand my pians"I M uwtl as public mends
Licensed Professional
OWNER-BUILDER DECLAR
ATION
1 hereby.(lifer that 1 1. exempt from the Conoecm o Licence Law for the
pO following reason.(Section 7 onsst.Baines and w.de oli Cade:My m Or manly L]/
$Pi
which requires s permit re amavuct.alcor.nt prow,demolish,t or repair ed attacture Olen
H �^ that heprior its issuance.p elm nt to fu' fin Applicant ofthe CoIncn factur w eiens,le A Law(Cha mmlt
gg gay< (commecing wit pSectio70the of Division
of Nche usineiWmnmlawfC Code)
Sq.F[. Floor Area Valuation
tre (est he 1,
(commencing with Section7000)and of basis n3 the
theegod aaMPmfMYvi Ca")of
BB dui a 7 campy therefrom and far
mora for the ctkgW eampnon Any l pmnsen of
Section thin,five
eery red oll far•permit subjects dae apPlient m•civil pealty of 3 g9DFJ.I�iJ�per0 0 Occupancy Type
not mart dun fiw hundred doltsrs(5300).
0 1,As owner of the property,or my employees with wages an their sole compensation.
will do thewort,and theawndpm Is nmimmnded aro@rod forale(Sec.7044,Business
and Professions Code:The Commarres Liceve Law does rot apply m 00 owner Of Required Inspections
property who Wil"arimptaveslhermn,and whodassmh wok himself mUuaugh his
Oxo employee.provided thatswh improvements Are not intended uroQemd("sale.If.
however,the building or Improvement is sold within ane you of completim,the owner.
builder will haw the burden of proving that he did not build or improve for purpose of
akJ.
0 1.as owner of the property.am excluswly contracting with Bcenad contractors to
com rent the project(Sec.7044,Business and professions Code:)The Contractors Li-
cense law dean not apply An an owner Of property who buil"or impfows daemon.and,
who contracts for such projects with a eontnewr(U licensed pursuant to dm contractor's
License Law.
O lamacrepturrom See .B&I`Cfordtismsma _
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby aline under penalty of perjury ane of the following dwlanayloa:
I haw end will mainuln acWnom of concent m elf-iaum fowodur SCWPem
sation,as provided for by Section 3700 of the labor Code.far the Performance of the
work for which this Permit is island.
0 1 haw and will maintain Workers Compensation Insurance,As required by Section
37W of the Labor Code,for the performance Of the wort for which this permit isIssued.
My Workers CorepeeNan Insurance other and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EREMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section wed Amt be completed If the ranch is for one hundred dollars(S 100)
or less.)
I«Nfy that in the perforreanm or the work for which this permit is issued.I shall not
employ any Paan in anymaws beco ybjwllo Ne Worken'Compenu0an
Laws of Califor a 1
Applicant
NOTICE TO APL TI:If,after making Nls Certificate of Exemption.Yen should
become subject m the Worker's Compmualion provisions or the labor Cade,you most
.,0 foMwith comply with such provisoes w this permit shall be descent revoked.
CONSTRUCTION LENDING AGENCY
rA[ti I hereby Him that there is a construction lending agency for the perfmmanea of
rL the work far which this Permit is issued(Sac.3097.CO.C.)
QLenders None
z lenders Address
fJ Q I cenify that 1 haw read this application and sum that the show InfarmNun u
;-+ correct.I agree to comply with all city and county ordinances and mute laws misting to
0 SV' building conswetion,and hemby umborie reprtanutiws of this city to enter open the
I37 above-memioaed property fm inspection purpoas.
C6 (We)agree to saw.indemnify and keep hanekaf Ile City of Cupertino against
A,w y liabilidea.judgmentAcosts mdexpenca which mayin my wayaccrue agains(Wd City
U in
APPLICANT eUNDERSTANDS Aoften gambling of AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
t ER I�TI � l _ 1 ( It o5
Re-roofs
Signature of Applica.WConuamar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Has applicant Or future building mcupant[arc or handIc baadae mawris
As defined by the Cupertino Municipal Code.Chapter 9.17,and the Health and Safety
Cade.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Own ON.
Will the applicant of future building occupant tea equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it WIN=air conueinants As dcMed by the Bay Area Air Quality Management all new materials for inspection.
iwic@ �
Eyes LJwu
I haw mad the haardnus materials requirements under Chapter 6.95 hfthe Califor.
nice Hu W tl SafctyCadc.Sections 25505.25333 and 25534.1 unAkmund that irthe building
does not emmntly haw a tenant.that it is my fespomihiliiy m notify the occupant of dae
ACAlaiwmamaw ch mute me brtv5auar(IDA�fa`CeNfinxIOpeypanly.� Signature of Applicant Date
Owner or aatnarieed agent Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
coo Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS- PERMIT#
OWNER'S NAME: f3c(J PHONE #
GENERAL CONTRACTOR 6-156um / FAX #
I am not using any subcontractors: Il+ .) 5
Signature 0 Date
Please check applicable subcontractors and complete the following 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
X Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO Z.
REPIPE/SEWERS/MAIN SERVICE G1�
CUPERTINO PERMIT APPLICATION FORM
APN# 3 S ,7 Date: , ` /J 05
Building Address:
7q &`/ of-L,n, eLL
Owner's Name: ty Phone#:
Contractor: Phone: License#:
�C� So>J �l o �nbl Nei z$o 53 / 1
Contact: , d� Phone:yof s& S I/ Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb (�
Job Description:
pipe - coyP4R-
Residential ❑ Commercial ❑
Cost of Project: yf
•
Qty. if
Applic4ble Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFD{TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING