The URL can be used to link to this page

05040151 (2) CITY OF CUPERTINO Mid "A. N' . `WNTAA QRT � ai BUILDING DIVISION PIRMIT Kt9 t ,..?iY w4. zi7CAvct4ID3 g w;b,r . " BUILDING ADDRESS: PERMIT NO. MASTER PLUMBING & SEWER IN 05040151 AM PERMIT ISSUE DATE HE SANITARY OL N0. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH p yCj LICENSED CONTRACTOR'S DECLARATION Job Description 01 1 hereby affirm that I am licensed under provisimu of Chapter 9(commencing Z with Section 7000)of Division 3 of due Business and Profs m Code.md my license is ` in full force and eIf uaenmCa f Lle.0 Q51 z 3L INSTALL CLEAN OUT Deus C...r g� lvtw.t ARCHMCrS DECLARATION 1� I understand my plane shall he used as puhlk rtcold, ' Liecued Professional •r, OWNER-BUILDER DECLARATION E 1 hereby aMrm that I am exempt fru.The Contractors License Law for the i00 following mason.(Section 711313.Business and Profession,Code:Any city or county $tri which requires a Permit to MWOW L,alar.improv,demolish,or repair my structum priors,its issuance.also requires the applicant for such permit 10 Bleevigncd statement a�y< that he 1s licensed pursuant to she pmvlsions of the Contractor's Licence Law(Chapter 9 oo rValuat CO (commencing with Section 7000)of Division3nflhe Businusand Pmfeulon,Cmk)or Bat he is comps tMefmm and the bash for Base alleged!eau mpUm.Any vmladm of ecuP y�'Pe Section 7031.5 by any applicant for a permit subjects the applicant to a civil washy of not Ilam an Ilaaw hundred dollen(g300). 3 �I�F I�erO 0 , anC ❑1,u awnu of time property.ter my employes with wages a tial,role campeuallon, will do the work,and themucctm la..Ioriented mmReed for anis(Sm.7001,Business and Profeuious Code:The Conuacmra Liceuse Taw des net apply to An Owner of Required Inspections property who but Ids or Ian proves Neem,and who transmit work himsel f ar through his own employes,provided that such improvemenu tae not Inanded c roaered fm ale.If, however,the building or Improvement is mid within was you of completion.the owner. builder will have the burden of proving that he did Out build or Improv for purpose of "I.I. p ❑1,a owner of the property,ant exd ss and connecting with licensed contractors l. (�® 01.aconstruct the projece(Sec.7094,Business red c onecti ng Code:)ene contractorsLl. 0 !rq came law time not apply to an owner of property who builds or Improver thereon.and, who contracts for such projects with a eunuacthNO licensed purism to the Contractors 0 ensel Ism ann law. ❑ exempt under Sca ,Bd:PCfar this rcawn t3700.1' ner Dau WORKER'S COMPENSATION DECLARATION99 I hereby afros,under Penalty of perjury one of the following dmlartlionc ®®® CQOC Iba.end will maintain a CeNficau of Consent to self-hue for Workers Compo- ® JJ on,u provided fm by Section 3700 of the labor Code.fm the pedamtarea of the k for which this permit is issued. 1 have and will maintain Worker,Compensation luunnce,ss requled by Section Ne labor Code,for the performineeof the work fa which this pent,Ie Issued.Worker,Compensation Imm�nce main and Policy numbers.: ier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE Cousuctlm wed not hecamplead true peters Is form.hundred dollen($100) or 1 certify that In the performance of the work for which this permit Is issued.I shall not employ any permn In anym�r /rob T mma Mc a Subject to the Worken'CompemaJon Laws of Caiifomic Date t1. Applicant NOTICE TO APPLICANT:If,after making this Cedlacete of EaemPtion,you should become Subject 10 the WorkeM1 Compensation provisions of the labor Code,you mud ,JO forthwith comply.11h two provision m this permit hat be deemed raveled. CONSTRUCTION LENDING AGENCY (~ I hereby affirm that them lex construction lending agency for the performance of lX 7 the wort for which this permit Is lewd(Sec.3097.Civ.C.) W Q lenders Name �v z Lender's Address .0 C 1 unify dual I he.reed this appllutlm and sus dal the abow Information ie W F tonnes.I agme to comply with all city and county ordinances and mate Ian gilding to O U building eonawction,and hereby a.hodm rtpreantethca Of this City to enter upon the W above-mentioned property for Inspection purpous. gy (We)agree to an,indemnify and keep humku the City of Cupertino aping fA liabilities,judgments,costs and expenses which may In any way acerae against said City V 7 In consequence of the granting of this permit. G7 APPLICANT UNDERSTANDS AN9,WILL COMPLY WITH ALL ON-PgINT Issued by:9 Dale souj)e�(f1.Ano c K!/ /y Re-roofs Slgnan A pllesHAZ t e1� HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the applicant or future building e.Chapter u.e or MtMk hazardous material u dented by she Cupertino Municipal Code,Chapter 9.13.and the Health and Safely ,SLED Section 1353i(I" L' All roofs shall be inspected prior to any roofing material being installed. ❑Yes RWu win tha.ppuexm m mwebolldingmeapam umeympmmtordevies whmh If a roof is installed without first obtaining an inspection,I agree to remove It hazardous air contaminants a claimed by the Bay Area Air Quality Management all new materials for inspection. dricli ❑Yea Flo 1 have mad the hazardous material,requirements under Chapter 6.95 of the Celifor. nle11u1duRSaitoyCede,Soniou 5115,25573 anJ333N.1 unclnuM dust lithe Welding Jwa netc ly have as 1 r ,ts myeapmtslbility a ow,IYIbe ups, adue myul wmcnmO a riurctkmance.racenlacaw mer. ignature of Applicant Date Ow amharisde nt rte All roof coverings to be Class„Br,or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 coo Fax(408)777-3333 �UPEI�TINO Build.ing Department JOB ADDRESS: PERMIT#p �� — OWNER'S NAME: w t PHONE # GENERAL CONTRACTOR FAX# 6 I am not using any subcontractors: _ L Signature D to 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO0 REPIPE/SEWERS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# ! � � � Date: 2 0 Building Address: 2c� ? 6 3 5 4e1.,t. "f -c le-- Owner's Name: Phon ontractor: � Phone: I � �W License 2 ,3 � Co Phon : Cupertino Business License#: 2500 -Building Permit Info: Bldg ❑ Elect ❑ Plumb Job Description: A3 6/i Residential ❑ C mmercial Cost of Project: • Qty. if Applicable Fee ID Fee Description Fee Group PPERMrfFEE 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 Dis osal PLUMBING BUSLIC Business License BUILDING