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04090096 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT xk� NTRA T IN,INVORM T-10� OUILDING ADDRESS: PERMITN'0 4 0 9 0 0 9 6 n212 RANTA MARA A17• OWNER'S NAME: PERMIT LSSUHDA7E LARRYGARCIA SANITARY 0. 16,12 OL NO, ONE: ARCHITECT/ENGINEER: BUILDING PERMITINFO E MECN 0 u00LICENSED CONTRACTOR'S DECLARATION 7obDescriptio (y F 1 nemby affirm that I am licensed under provisions of Chapter 9(commeming Ey wish Section 7glU)af Division3of NC Boo wand Prafessium Code.mdmyliccnuia a� infdBYpme and cf �'qz Lieen�e class ` ,3Cp L 7K L5 1 REPIPE FOR 2 1/2 BATH ROOMS OCT k 2004 Dam conn r CONTRACTOR: D' S PLUMBING ARCHITECT'S GECLA ON U �un�g dnYPla sebyl udupuM1l'mmcoods BUILDING u. Lice LLLLL�� mfcesianal t O OWNER-BUILDER DECLARATION x I hereby affirm that 1 am exempt from the Contractors License Law for the p O following mason.(Section 7031.5,Business and Professions Code:Any city or county $(< which requires a permit to construct.alter,improve,demolish,or repair any structure F Z} prim to its issuance,also requires the applicem forsuch Permit w rile a Signed statement that he is licensed pursuant ro thc pmvismosa the Contractor's Leon.I..(Chapter 9 Sq.Ft.Floor Area ValuafAOf1500 $ (commencing with Section 70)0).(Division Sof the Businessand Professions Cnde)ur '?4 ton he is exempt therefrom and the basis far the alleged tampion.Any=of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not come than love hundred dollars($500). 01,uownuofshepmpeny,ormyempl.yeuwithwagesuthelruiccumPen2¢tion, 32622006 . 00 willdo tite work and theswctua isnot imm�dcd moReretl rorsa1.(Sec.7W.Business and professions Cc&:The Contractor's License Law does nut apply a an owner of Required Inspections pmpenywhn builds orimpacm thereon,andwho doessuch workhtmealforthrough his - Own employees.provided that such improvements are not intended oroRered for me.If. however,me building or improvement is aid within one year of completion.dee owmr- buiuer will hove the burden of proving that he did not Wild or improve fm purpose of sale.). ❑1,a Owner of the property,an exclusively contracting with licensed contractors in construct the project(Sec.7044,Buimam and Professions Code:)The Contramra Li- mine law does not apply to an owner of prepeny who Wilds or improves themon.and who contracts for such projecm with acon some r(s)licensed pursuant to IW Contractors License law. ❑1 am exempt under Sec. .B A,P C for this reason OwnerDam WORKERS COMPENSATION DECLARATION I hereby affirm under Penalty of perjury one of the following declarations: J 1 have and will maintain a Cerifiam of Cement to self-insum for Wmker'aCompen- notion,as provided for by Section 3700 of dte Later Code,for mO perfommnce Of me work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as requited by Section 3700 of me labor Code.for the partowanec of the work fm which this Permit is issued. ' My Worker's CnO oval onlnsurance caner and Policy n r au: f•=,rico In�Lf 14 CG_. Polity FROM ✓�// CERTIFICATE OF EXEMPTION Fl o.: WORKERS' COMPENSATION INSURANCE (This.man need ata t he tom plated if me Permit is for arc hundred dollars(5100) or Ica.) 1 certify mal in the performance of the work for which this permit is issued,I shall not employ any person in my mushroom as in become subject to she Workcrm'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:If.altar making this Ccnifcase of Exemption,you should become subject in me Worker's Compensation provisions of the Labor Code,you must �Q forthwith comply with such provisions or this Permit mall W deemed mvoked. ,Z-r CONSTRUCTION LENDING AGENCY [ti4 I hereby affirm that them is acoutmctlna lending agency for the performance of f1i 7 the work for which this permit is issued(Sec.3097,Civ.C.) aQ Lenders Name Z Lender's Address V C) I unify met I have read this application and mute that the be.inf moral n is {Ta cored.I agree to comply with all city and county ordinances and muss laws relating In p building concoction,and hereby aullorla representatives of this city to tour upon the above-memdoned pmpeny for inspection purposes. (we)agrte to save,indemnify and kap hamdess the City of Cupertino against tA liabilities,judgments.costs and expenses which may in any way accrue against avid City 711�Aoo of me V APPLICANin T UNDERSTANDS Atarting ofrNDWILL COMPLY WITH ALL NON-POINT Issuedby:9 Date S C tR GULATIO /, . L d xL az."_ /1 I- ��'6q Re-roofs uumaf ApplicmVCommetor Date HAZARDOUS MATERIALS DISCLOFuhE Type of Roof Will the applicant or future building acupantstom or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety oda.Soman 2553x41 All roofs shall be inspected prior to any roofing material being installed. ❑Yu $No Will the applicant or future building Occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove emit havardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes �}Ju 1 have read the Woodcut materials requirements under Chapter 6.95 of the Califor- nia Health&SafnyCodc,Sections 25505,25533 and 25534.1 understand that iflW building does not carnally haw a kris,that it is my responsibility to notify the occupant of the rcyui ntswhichm IpdormissuanaofaCcm atearOceapaney. Signature of Applicant Date I I' O All roof coverings to be Class"B"or better Owner or amhmiaod agent Dom Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 aClOF Fax(408)777-3333 �UPERTINO Building Depqtment JOB ADD SS: PERMIT # 10212. SA h1TA CUA RA AVG , 0409 �c0 OWNER'SN , LAP,?, Al C A PHO # 4�0%- ZSI - Sq-L GENERAL CONTRACTOR: VS p Lu nti b i Nk L FAX #' I am not using any subcontractors: 8zwC,,-..4; P gf� 9- 1 (,- 04 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving flastering lumbing 7'5oofing septic Tank Sheet Metal Sheet Rock Tile S / ontractor Signature Date CITY OF CUPERTINO WREPIPE/SEWERS/MAIN SERVICE c� c5 �1 CUPERTINO PERMIT APPLICATION FORM C APN# Z/ z Z � a /' Date: Buildin Address: b I 11 5 A -r CLA q x vE Owner's Name: Phone#: .40a L f-1 RRA G r-) +a = --19 S9 Contractor: Phone: ®$ License#: 'b & 5 a LU n/A b 1 r.l G 2.51 -5 4 Contact Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb Cl Job Description: 'RE P I PE 'Co C'oPEIZ- 2 7SO N lZoc7 vv� Residential ,�' Commercial ❑ Cost of Project: C Qty. if AppD64ble Fee ID Fee Description Fee Group PPERMTTFEE Plumbing 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