05020183 (2) r CITY OF CUPERTINO I'' _V " _
BUILDING DI VISION pTil MIT ° '� r z°ACT�Q= TNFU ATT'('/N
'hay?,
BUILDING ADDRESS: PERMIT N%5020183
LAND DR
OWNER'S NAME: PERMIT ISSUE DATE
ROM SHAW
RPIONE: SANITARY NO. CONTROL NO.
ARCHITECtrENGiNEER: BUILDING PERMIT INFO
BLDG EI.CCT PLUMB MECH
�op LICENSED CONTRACTORS DECLARATION
of Chap Job Des`cri tion
+� 1 hereby 0)of that 13 Iicensd under provisions of Chapter 9(commencing p
wlNll was,70,10)of Division lof the Business and Professions Code.and my license is
nr.can ceendercm REPIPE & WATER HEATER REPLA ENT
jg� Daw Clw ue.g
z Dam Contractor CONTRACTOR: BETTER PLUMBING
g.."IARCHIhe use DECLARATION
50( I undersi`yl my Plana Nall W used u Public rtcods �Ayv ® .
1111CCCC Licensed PmfuI d... GJY 'Y/r
OWNER-BUILDER DECLARATION
I
1 hereby arm et I am exempt from the Comnun LinIo far the <20�
D D following reason.(Section 70313,sudmss and Professions Code:My city or county
$ which requires,a permit to mamtrom,alcor.Improve.demolish,at repair any structure
prior in its iuuance,also requires the applicant for each permit to rileulgned statement
waa he is licensed pursuant to that provision of the Commutes Luentac Law chapserli Sq.Ft.Floor Area "a�� pA Valua$V500
$ mermemdng with Section 7000)of Division 3 ofde Butincasand Professions Cow)or O (I/'
e<.. that M Isesempt therefrom and the basis fm the alleged assumption.My violadon of b
Seodan7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number v Occas ane
Inst come than five hundred dollen(5300) 32628013 . 00 Number
� p y Type I,asawnu of the property,army employees with wagesas thehsole compenndon,
will do the ooh,and thestrucaa is notinended mattered fond.(Sec.7044,Business
and Prefeeelons edw The Comacunes License Law does rot apply to an awner of - Required Inspections .
p tpertywM WIIW mireproxu therem.and whadrcssueh work himself.through his
ownemployw,provided that mh improvements are not Intended moQerd for ad&If.
however.the building or Improvement Is mid within mm year of completion.Ne owner.
builder wall thaw the comm of proving that he did an,build or improve fm purpose of
sale.).
0 I,as owner of the property.am exclusively cams saing with licensed mntncmn at
construct the pmjem(Sec 70m,Business and Profession Code:)The Cmtnemrl U.
cease Law does not appy to an mover of property who builds or improves demon.was,
who contacts for such projects with a eonuadmis)licensed pursuant in the contractor,
ase Law.
l am exempt un sec .B&PClm this re
owner
c�llM i@ fiGM NSATIONDECLARATIO
1 hereby affirm under parody of perjury on of de following declammur
❑I have and will maintain a CeNfiom of Consenuo self-Inswefor WarkaraCamper.
much,as provided for by Section 7700 of the Labor Code,for the performance of the
work for which this permit Is issued.
0 1 have and will maintain Workers Compensation Immanent,as mquieE by Section
3700 of the Labor Code,for the performance of the work for which this permit is loud.
My Workers Compensation Insurance mother and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This names owed Out uncompleted if de permit Is foram hundred dollars($Im)
or Ices.)
1 cenify,Not in the pmermame of the weak for which this permit is Issued,I shall am
=ploy any person in my manner so as in become abject as the Workers'Compensation
Lew,of Cdifomla.Dem
Applicant
NOTICE TO APPLICANT:If.der making this Certifiom of Esemptio.you should
become subject m the Workers Compensation Ismisions of the Labor Code,you must
.,Q forthwith comply with each provisions m this permit shall be deemed revoked.
,z.i r~�i CONSTRUCTION LENDING AGENCY
F' Iherebya0hm was then is a convection lending agency rmthe performance of
�i the wart far which Nu permit IF issued(Sec 309'1,Civ.C.)
Q Lender's Name
=z T'ndees Address
U Q 1 certify that I have read this application and sou the,the above Information u
{s. coram.I agree to comply with all city and county ordinances nd mu lows ma0ng to
Q building cmuuuction.ad hereby authodec representatives Ofthts city in enter upon fie
W ah rm-ram ored pmpcny for Inspection purposes
6. (We)agree to save.indemnify and keep harmlev the City of Cupertino against
CA lidlims,judgmcnu,cots and expenses which may in my way atcems aSaint said City
L)Z in mruequence of de gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC1 _ �
� 2Re-roofs
Signature a r Dau
E REG�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant sum at handle hav4mmus material
u defind by the Cupertino Municipal Code,Chapter 9.13,and de Health and Safety
ode,Sedmn:ss3z(.)I
❑Yes TbINa All roofs shall be inspected prior to any roofing material being installed.
Will ft applicant OF future Wilding aecupent use equipment OF&vim which If a roof is installed without first obtaining an inspection,I agree to remove
emit)unmans air coominanu as de0md by the Bay Area Air Quality Management all new materials for Inspection.
DimicO
C]Y. fbiu
I hive mad thehnardmsmaterials requirements underCheperb.95 of the Cdifur.
me Health&SafmyCode,Sodom 75505,75533 ad25534.1 undcmad duUfthc Wilding "� p
rims no,currently have 4 that It is my responsibility a ratify tie comment of sire
requimne dIIC tropia 'asuamcofaQertificauof Signal Date
Owner mr,n maasaapan '� Q„p All roof coverings to be Class"B”or better
Community Development
10300 Torre Avenue
r Cupertino CA 95014
Telephone(408)777-3228
oclo Fax(408)777-3333
IUPEkTINO
Building Department
JOB ADDRESS- (//r Z p v! A �� PERMIT #
`I t v OS�OZD/g3
OWNER'S NAME: /Pon 5Air W PHONE #
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: 2 spas
ignature 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
Plumbing w ✓m 6,4
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owne gnature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE o -C)2 Q/��
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: ,,//" Phone#:
,e0%1 V�KAG✓
Contractor: Phone:
License#:
�1o8-z(3S� 33 7226 y3
Contact: Phone: Cupertino Business License#:
H/llfn—.
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
.CMCJ ' e4 �Ce
Residential Commercial ❑
Cost of Project: 44
•
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
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 Disposal PLUMBING
BUSLIC Business License BUILDING