05040128 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �fSIRAC'Y�'ORI�NFC1'C�1VIAT, 4Ne. "
BUILDING ADDRESS: PERMIT NO,
FALCONE PLUMBING & HEATIN INC 05040128
OWNER'S NAME: PERMITISSUEDATB
HE
AVE, SANITARY 0 OLNO.
ARCHITELT/ "B"ER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
I� o
�oo LICENSED CONIRACf00.'S DECLARATION Job Description
(y FF 1 hereby affirm that I am licensed under previsions of Chapter 9(commencing l
with Section 7gM1)of Divldon3of NO Buaineu end Profnsiona Cede dmylicenxta 1
in full force and offgcI C7
5�? Licenx C7us Llc.. INSTALL
Dee Conlaaror
ARCHITECTS DECLA TI
'� I undertunJ my plan still be used u puM1 c ranrN ,' ';
Liccnxd Professional
a
8� OWNER-BUILDER DECLARATION t t[tI
I I heresy Jana that 1 am1. exempt from tic CnnuanCo eA License law for Ibe 1
p O following reason. a mit t 7 onstru t.Allesl and Improve,
de tom Code:Any oily Or county
which eyulms a permlT In construct.site[improve,demolish,nr epmr any atruetua
pd.,m its lumnce,also requieatheapplic"i(.'such recall x file asigudsutemem
< that he is licensed pursuant to the provisions of ftContrutors License law(Chapter9 Sq.F[. Floor Area Valuall0
te (commencing with Section 7000)of Division S of Me Bminoumd Professions Code)or
$ Nat he is exempt Ihexfrom And the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicantto to.civil penury of3 �,�(glglaer 0 0 Occupancy Type'
not mare than love hundred delta.($500).
❑I,as ownerafthe pmpeny,mmynmployces with wa{esuNelrsolecompenutlon,
will do the work,and the muctum is not intended craaered(mute(See,7044,Business RequiredI Ctions
and Professions Code:The Committees License Law does ret apply x an owner of
property who bu Ilds m improves daemon,And who doe ouch work bleaself or through his
own employ=,provided that such Improvements Are notlnureed ara02eed fmsma If. ( -
bawevcr,ill haw the b r Improvement is mid rue did
an yearbuild
ofcompleta improw on.Ibepose owner.
of /
builder will haw the burden of proving Nu be did nal build m improve fm purpose of
ole,).
❑1,as owner of the property.,B exclusively and
coneudn{CIN:)Theed n"Caxn to g�(
constructamLa the project(Sec,o an Business and Pro essionswho Wild,
Code:)Theves do on. red V`
come law docs not applytoan with
a of property who builds or Improves demon,and V
who cantata far such projects wish•conuActor(O Ilceamxd punusnl m the Conlrutoh
1 amnse law.
0 Lem exempt under see. .Bit PC(or this moon '
Owner Data
I WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury aro of be following declarations:
I haw and will nu nuln•Cudilcros of Consent to self-insure fm Worker,Compere
u0on,ru provided for by Soden 7700 of the labor Code.for Ne Performance of the
work for which this permit is issued.
❑1 have And will.AinWn Workers Crop ensAllen Insurance,As expired by section
7700 often Labor Code,for the performance of the work for which this permit b iasuW.
My Worker,Compeuatlagjrtsursaw carrier and Policy number am:
GMer.. ��� `�'t-/1 PoIIry No.: 3O [27�� 3
CERTIFICATE OF EKEMPTON FROM WORKERS'
COMPENSATION INSURANCE
Olmta section reed awn he completed if the permlt is far.hundred della.(SIM)
tor less.)
I certify that In The performance of the work for which this permit if issued,l shall not
employ anyperm.in any murer sn as An hesame subject to Tie Worten'Compeu.ion
Uwe ofCalifornia,Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in Na Workers Compensation previsions of the LAW Cote,you mum
,J 0 forthwith comply with such provisions or this permit mail be deemed revalued.
74 tiCONSTRUCTION LENDING AGENCY
N (hereby airum Jr.there is eonstacdnn lending agency for the performance of
the work for which this permit B issued(Sec.AN7,Co.C.)
WQ Lenders Nam.
Z)Z Landers Address
U Q I eenlfy that I haw read this application and rob that the above Information Is
carr.ct.I agree 10 comply with ml city and county ordinaan and/tsts laws relating to
O EC'7J bulldin{con tion,And hem6Y y!Ihodx¢paunutivu of this city to mkr upon'site
W ahovcme on d propertyforiupeNon purpeses.
(We)e e to sew,indemnify W keep hmmleas the City of Cupertino agmmr
fax Ilebilldei.jud eau caNmulixpenses which may In any way accrueagalut said City
fJ 7 In eanirgmnW1mW1r*of Nis permit.
L7 APPLICADSANDWILL COMPLY WITH ALL N-POINT Issued by:91t�&o Date- t y j
Re-roofs
gnawrc of ApplleeHAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applcant or forum building=upset come or handle haurdaus material
As defined by The Cupenlno Munid At Code.Chapter 9.11,and the Health and Safely
Code,S.O..25572(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
WIII the aoor future building Ocse occupant uequipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
It haartom air
lr contranlaminanu As J mod by the Bay Area Air Quality Management all new materials TOC mSpeCt100.
inrict7
❑Yc u
I MvcreW hanrdnus ler luequi..n"under Chaper6.95orlhe CalifoP _
nix Health&Safcry aqC 25 5,25577 And 25534.1 undo [Urfm00o
docs ren cureall
�y/ha✓c a , N ('m my res y the cecupent of the
requirements wryp' a mt «of a ccnincte or Occupancy. Signature of Applicant Date
Owner nulhorizedagent Dole
All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fa Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS:;O/4 G Cue k Q/v ERMTT# 0 �,-v Q/ -z r
OWNER'S NAME: C vcG ' PHONE # ,377-//0 o o (�
GENERAL CONTRACTOR ACt)n e. -PI � /S d FAX# 2 3 - S 7-
I
I am not using any subcontractors: 1 L U
Signature Date
Please check applicable subcontractors aL 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
Roofing
Septic Tank
Sheet Metal
Sh t Rock
ile
2��s
Owner/Contractor Signature Date
rCITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE O S--b
CUPERTINO PERMIT APPLICATION FORM
APN# ll wo L 3 Date:
Building Address:
Owner's CName: Phone#;'R�-L ,377-/6a o
Contractor,y— /Cl�7Pi //� Phone.. g9 3 -5-6 -76 License#:
7�7Uvyl�$ln of aTi
Contact: ���G Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
TpLL Sege, Clea oar /3
Residential ❑ Commercial
Cost of Project: OD a�
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbin-g Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pb] . Fixture PLUMBING
BPWSVCS . Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING