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05090125 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT �CCINTRAC fnR INFORMATION '°;~. BUILDING ADDRESS: DIJOSEPHtS PLUMBING PERMTND'05090125 OWNER'S NAME: PERAET ISSUE DATE JOSEPHINE NE: SANITARY NO, CONTROL NO, (408) 365-2058 ARCHI]EC IENOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Q I� C LICENSED CONTRACTOR'S DECLARATION Job Description iF 1 hereby affirm that 1 am licensed mnsed under provisions or Chapter 9(commencing n<n will,Sation7")of Dh,bd..Tar the Business anal 9 � — t ProfessbtCde,an. my m Is in full firms /gClgZ COPPER REPIPE ARCHITECTS DECLARATION F I A LED Q i untlenunJ my plans shall he used as puhOc rtcnrm o Licensed Professional SEP a5-2005 OWNER-BUILDER DECLARATION ZZ 1 hereby.(Sunt on I am exempt from the Conmcwr's License c Law tar the O O following moon.Permit i IID L$Business and n,de oro Code:Any city m countyyy-^..p �@r S$ which mqubu•Pmmit re enruwet,alms impmw,demolish.t ri e a sig any awcturc IlcL [A vg, y ��y 9 0 poor mits iensedpalmntrequires provision offmwch pctmitwfileasigadwwmcnt emr3 Lee F o that leullcjwit pursuant in as of Disiomo(them Buttress ll Proetaw(Chapom9 Sq.Ft.Floor Area l Y . rl V�IU�O e (cam a Is exe with Section odor"and of basis 3 of the Bminessund on.My Code)don or of — Nat he u exempt therefrom cosi the bm6 fm the silegW exemption.My violation of Section 7031.5 by any applicant fm a permit subjects the applicant w a civil penalty of F Occupancy Type net more mm fin bundrcd callers($500). 0 Lssownar oftie property,mmy employees with wagesmthehmle compensation, will do the Mut.and the mucdum Is notlmmnded aaBeted frrssm(Sec.7044,Business and Professmm Cede:The Camacwr's Lan r Law does an,apply m m Rewired Inspections owner or q p tions property who bu Ilds m i mpo wes thereon,aha tuna don much work himself ar through his own employees,provided that Such Improwmenu are not intended material for We.if, however,then building erimprowmen,is mid within one year ofcompieolon,the owner- builder MR have the burden of proHng the,he did not udld or impraa far purpose of 0 1,as owns of ole Property,am exclumndy canonical.,with Hamed contractors m construct the project(Sec.7044,Rosiness and Profrssiom Code:)The Contracmta U- cena law does not apply in an owner of property,who builds or improves Ramon,ad who contracts for such projects with a cmtrmwr(a)licensed pursuant w me Contractor's License Law. 0 l am exempt new Sm. .B @ P C for this maxim 1037�10,0 ns Data WORKERS COMPENSATION DECLARATION I thereby affirm under penalty of perjury am of the following declarations: I hew and will meimain a Certificate trounces w self-Wpm fm Weiler.Compe.- nn,a provided fm by Section 3700 of the labor Cade,for the Performance of me rk fat which this permit u isSued. 1 have and will maintain Worker's Compwation Insurance,ss required by Section of the Labor Code,far the performance of the work fm which this permit is Wood. Worke/1-.empanladan Insurance camior cosi Policyier, �'aprS PolicyNo.: CERTIFICATE OF EKEMPTION FROM WORKERS* COMPENSATION INSURANCE (Thissec,lon teed not becompleted Raw permit Is A rans hundred dolls¢(SIM) or alas) 1 certify that in the performance of the work fm which this Permit a Issued.I shall no, employ any Person in my manners as in become subject in me Workcft Compenladon Lawes of California.Data Applicant NOTICE TO APPLICANT:If.after making this Ccra ficae of Exemption.you should become Subject to the Worker's Compenladon provislom of the Labor Code,you must .,O forthwith comply with such pmvisiom or this permiuhalt M locoed mvo4d, z CONSTRUCTION LENDING AGENCY I hereby affirm that them is a contraction lending agency for de performance of ai the work for which this permit Is issued(Sec.3097,Civ.C.) W�0 Lender's Name D Z lender's Address V Q 1 arufy that I haw rad Ws application and me that the above Infermadon Is Iy!' corrin 1 agree in comply with all clay and county oNlnanas and sum laws relating In O kr J^ buildingconstruction.and hereby aumorim representatives of this city to enter upon the W shove-mentiond property for Wpemlan purposes g3, (We)agree in lave,indemnify and kap harmless the City of Cupertino against lhatfiRu,judgments,ants and expenses which may In any way acme agalm,said City () r77 in comegmnca of me granting of this permit. qq APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR REC AT10NS. )/� � � _ %%=) &� /`'r�`G's Re-roofs Sir' Signature of ApplicmVComncwr Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or futmo building occupm,store or handle huardous material as dinned by de Cupertino Municipal Code.Chapter 9.13.and the Health anal Safety Swam 25533(.)7 Az roofs shall be inspected prior to any roofing material being installed. OyuWill the applicant of future building occupant me equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove ml,hmardnm air contaminants m defined by the Bay Arca Air Quality Management all new materials for inspection. District? 0 Yes AN. I ban mad the haranhma materials impairments underchep ar6.95 of the Califor- nia HcaW&SafctyCedc,Sectiam 25505.35533ad 35534.1 understood thatifthe building does not currently baro a commit.that It is my respommithy to totally the occupant or the realm ants ichmustbe ro islamccol"GNfmamafOc cy Signature of Applicant Date r' _2 All roof coverings to be Class"B"or better Owner unmborivod agent Data - Community Development 10300 Torre Avenue f 1 -✓' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPE(�TINO Building De artment JOB //33 7 F ADDRESS:57 POol-ep b/ ( L/�'°/�i'y 0 PERMIT # OWNER'S NAME: do PHONE # ? 2- / GENERAL CONTRACTOR FAX # I am not using any subcontractors: 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 Plastering Plumbingd i J�/y� �v S �'�kr j H I?k?r, Roofing Septic Tank Sheet Metal Sheet Rock Tile a):� Owner/Contractor Sfinature Date CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE OF $CUPERTINO PERMIT APPLICATION. FORM APN # 3 Z D (o O�2 l©O Date: l g GS^ Building Address: -3 Owner's Name: 10 S Phone#:�s.2 `6g� Contractor: �/GSre,4 S ��`yC Phone: 36 S �Gs.r License#: s Contact: .�,, p/�PS r/A Phone: SOS^�73 Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb H,, Job Description: 40, 1 �� GLq �rL d� S� fy. 0' �o Residential Commercial ❑ Cost of Project: (?7 Ia p d0 • Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS Gas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repipe of Fixtures PLUMBING BPFLYTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING