05010071 (2) e CITY OF CUPERTINOn �s,�� +' �: Ivr Avv l rs
BUILDING DIVISION PERMIT WONTRACTOR INFORMATI®N
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BUILDING ADDRESS: _ CHAMPION PLUMBING PERMIT 11005010071
RIO STENT)HAT, IN
OWNER'S NAME: PERMTTLSUEDATE
KWAI LAI 2059 CAMDEN2005
ONE; SANITARY NO. CONTROL NO.
(408) 437-1507
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+oo LICENSED CONTRACTOR'S DECLARATION -
£� I hereby Al Net l am lialuN under pmviy'ons car Chapter 9(commencing lob Description
i with Sc tion 01111)of Divi,ion)of the Businus,MTrgfusiom Code.,nd mylieeve le
Ln fullr nae cc ✓ V PROPERTY C/O FOR SEWER
.Zs
POi z u«n I lesI Contac n, — w y e I O /
J RATION
I un d lame 11 ossa u cram /
f 1- l -
A
O y, 'C d mreEel i
�yq 3 OWNE UILDERmptfr from
Contractor's
ON
2�y I hcrehy res Nol I a exempt from Ne Contrumr's Licenu 4w for the O.A
O O ( owing teao Section 7(D L5,Business and Professions Cask:Any city or county v
5$ high myuims a permit to construct.elect,improve,demolish,or repair any structure O
y prions its issuance,also requires the applicant rot such Permit to file a signed statement
< that he i,licensed purmont to On pmvid.n.of the Coionsur's Lienar law(Cupox 9 Sq.Ft. Floor Area Valuation
(commencing with Scction7000)car Divism.3 oohs Bminess and Prolinsamru Coub)or
$
that he Is exempt therefrom and On buss for the alleged emmption.Any violation of
'Section 7071.5 by any applicant fon Permit subjects Ne applicant to a civil penalty of 3'AP$TAA5r778er00 Occupancy Type
not more than five hundmd doll ars(5500). - . P Y YP
❑ Lo owrmrk.the property,structure myamplaynm wimwegmo Netrrole eompematmn,
will dodtework ands: oConismes Lt..
dmowred fonds(Sec,7()44.owner
and Professions Code;The Improves
Om tor. raw who
law does oat apply to,n ro uh is Required Inspections
property who builds m Impmwsat ch Imp!end who aeenot in woe himultonhrouMs
howOwn ever,dueers,ping or imrovememprowm nts within not ear dedof
completion,
fortune.ncr. -
builder Nebuildingorimprowmenlie sold withinone year of completion,pme upose of
builder will hoe the burden of proving Net he did not Wild or improv for puryou of
❑1,as owner of the property,em exclusively consisting with licensed contractors to
consumes On project(Sec.7010.Business and Professions Code:)The Contractor's Li. _
come law docs not apply to an owner of property who Wilds or improv thereon,and
who contracts for such projects with o conuu+or(U licensed pursuant to ase Convector.
License Law.
❑Ism exempt under Sec. ,B&PC for this moon
I
wner Dow
WORKERS COMPENSATION DECLARATION
I hereby affirm under Penally of perjury one of me following dcclaetions:
I have and will maintain
Certificate of Consent so self-imum for Workers Compen.
ion,m provided for by Session 7700 of me labor Code.for the Performance of me
rk for which Nis permit is issued.
I have and will maintain Workers Compensation Insurance,u requited by Section
00 of the Libor open,for the Performance of Ne was fo which Nis permR is Issued.
y Work'sess Cammou!�ll;a�n Insurance canner and Policy numhenm:
trier. Len tl'1 Policy 1p:Ft0dZB47,13sZOL
CERTIFICATE OF EKEMPnONF WORKERS'
CoMPENSATIONLNSURANCE
(Thu seellm need Out he completed if the permit is for aro hundred dollars IS 100) -
or less.)
1 certify that in she performance of the work for which do.Permit is issued.I Nall not
employ any person In any manner tai as w become subject to the Workeri Compensation
Laws of California.Dow
Applicant
NOTICE TO APPLICANT:Ir,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of she Letter Code,you mus -
.,v7,. forthwith comply with such provisions or this permit shall he deemed revoked. -
z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Net thea its construction lending agency for On Performance or
Yv .�
the work for which this permit 1.issued(Sec.3W7,Civ,C.)
:x1 A Lender's Name
z lendeh Add.
J Q I ttnify that I haw teed this application and soon that On snow inronnniun is
correct.I agree to comply withal]city and county ordinances and state law,relating to
building conevuNon,and hereby aohorim mpresenu0ves of this city to enter upon the /J
d ahovcmenliuned property for impeedon purpaus
r
(We)Agree to ww.indemnify and keep hamless she City of Crepe"I..against
h li.bllisln,judgments,cants d expenses which may in any way ecemc against aid City t
..) 7 sequencat she gran gollh permit.
Gi PP (CANT DERST 'CCOMPLY WJ]'H ALL NON-POINT Issued by: Dale
OU (CANT ATIO /,Yv///
Re-roofs
.Lure o App iea C n rechir Delo
AROOUS TERIALS DISCLOSURE Type of Roof
Will Nc appli a sur fumte bac ng Occupant store or handle hazardous material
defined by dte Cu mina Municip 1 Code,Chapter 9.11.aha me Hc.h1b and Safety
We,Section 25531(.)7 �., All roofs shall be inspected prior to any roofing material being installed.
❑Yes V4
Will the applicant or future building occupant use a.quipmcm to deviw which If a roof is installed without first obtaining an inspection,I agree to remove
is NUAnonds air contaminants o defmcd by On Bay Area Air Quality Management
Disuia7 all new materials for inspection.
[3 Yen QJI�
Ihave mW Nehaoranmmakrlau requirements under Chapter 6.95 Orme C,lifor. ,
iia Health&SafmyCcdc,Secu=25305,25533 and 25534.1 undemend thairdte building
orcuoe1I wa tint, tit I.hyftrommulily to nudity me Wcupanl of the
qui mentsw om mhe.teor cpency. Signature of Applicant Date
wear or aOthari agent Dak r of All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
pe
Crtino CA 9 014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEI�TINO
Building Department
JOB ADDRE�: 1 PERMIT #
g/ 0 05-() 1007 I
OWNER'S NAME: 7.-, 7, PHONE # q6 - 1,5-o2
GENERAL CONTRACTOR:nd, FAX #
I am not using any subcontract rs: / // -
Si tune Date
Please check applicable subcontrac s and com ete the following informati
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 of
Plumbing v Ip13 7 S 705Y
Roofing
Septic Tank
Sheet Metal
Sheet Rock
• T e
i - r� - OF
Ow /Contra or Signature Date
CITY OF CUPERTINO
WREPIPE/SEWERS/MAIN SERVICE
f�
CUPETINO PERMIT APPLICATION FORM
APN# _ Date: /
Building Addrre s:
n r c5, LJ
Owner's Name: Phone#:
CA. I & .
tractor: I Phone: License#:
Co
7fi o `PL 1t ✓I e r
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bld ' '❑ - Elect- ❑ lumb
Joc "
T R' sidenti - Commercial
Cost of P je t:'
Qty. if -
A is e Fee ID Fee Description Fee Group .
PPERMTI FEE
Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
Bldg. Permit Fees-. _ ::' BUILDING
BPFDXTURE Pbl . Fixture- PLUMBING
BPWSVCS Main Water Service PLUMBING
- BPSEWER : Sewers4 PLUMBING
BPSEWAGE Sewa a Disposal PLUMBING.
BUSLIC Business License • BUILDING
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