03100199 (2) CITY OF CUPERTINO ✓'n'*" >� +R�t;+xaa'xa'� 'a'' " .`-a> ...�
BUILDING DIVISION PERMIT rCON:TRACTORANFORMATIQN "
Bm1DINGADDRESS: GREAT AMERICAN PLUMBING CO IT14CN003100199
931 S TANTAU AV
OWNER'S NAME: 166 GRAHAM AVE PER1,1IT15SUEDATE
JONES DIANE W 10/28/2003
NE: (408) 995-6400 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
0 LICENSED CONIRACnOR'SDECLARATION Job Description
f 1 Wrcby affirm that I am Iittruc0 undo provisions of Chapter 9(commencing - P
with Section 70fXB of Division 5 o(the Business and Professions Code,and my license is
m fill farce and affect• REP I PE (E) BATHROOM
j N i Lima Claims Lir.N C A,
9 Dale �t-_'S(LQ Contractor bl II I1 ALIES®
fARCHITECT'S DECLARATION
I understand my plans shellWuud as puhllc rccnNs NOV 2 4 2003
).0
fLLo Licensed Professional
OWNER-BUILDER DECLARATION
j<x I hereby affirm list 1 am exempt from Bu Contractors License Law for the -
Oo following..air (Sec0un 703 .5,Business and Prefessimu Code:Any city m county BUILDING
3$� which acquires a permit m conamucl,eller,improve,demolish,or repair any structure6 0 0 0
-y6 prim m its issuance,also requires he applicant for such permiuo file a signed statement
EEss that he is licensedpursuanOntheprovisions(iftheContractor'sLiccnacLaw(Chapter9 Sq.Fl. Floor Area Valuation
tel-$ (commencing with Section 7")of Division 5 of the B usincu and Professions Code)or 37538049 ��
a ..
that he is exemia therefrom and the basis for the alleged exemption.Any violation of
Section 7051.5 by any applicant for a permit Subjects the applicant o a civil penalty of - n
APN Number Occupancy
not more than five hundred dollars($900). P Y Type
0 I,as owner of the property,m my employees with.,,a as their In compensation,
will do the wort,end the ewcture is not intended or offered far sale(See 7014,Business
and Professions Coda:The Conmctoh License law docs nal apply m an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or Unearth his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is and within one y.v of completion,the Owner.
builder will ban Ne burden of proving that he did not Wild or improve for purpose of
sale.).
0 I,es nine,of the propeny,am exclusively contracting with licensed contractors to
consumer the project(Sec.Buse,Business and Professions Code:)The Conuacmr's U.
cense law does not apply to an owner of property who Wilds or improves Merton,and
who contracts for such projects with o comnctor(s)licensed pursuant to the Contractors
Licca Law.
0 I am exempt trade,Sec. B&P C(or this...a
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declarations: -
1 ban and will maintain a Cenificnre of Consent o self-inswe for Workers Compen-
sation,as provided for by Section 57M of the labor Cade,for the perfmmonce of the
work for which this permit is issued.
Itt 1 have and will maintain Workers Compensation Incomes.as required by Secdon
5700 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Workers Com penutiorn homm ace carrier and Policy number art:
Camcr._57-AI,e F-"o Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secOnn need not W completed if the Permit Is for one hundred dollam(SIMB
or kin.)
I certify Nes in the performance-of Be work for which this permit is issucd.l shell not
employ any person in any menncrm as m Weome subject o the WorkersCompensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become Subject IB the Workers Compensation provisions of the labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there I..construction lending agency I'.,Nc re,furmance or
Ys the work fur which this permit is issucd(Sec.5097,Co,C.)
L Q Lcndcrs Name
7 z Lcnderi Address
t� 1 certify Nel 1 have read this application and more that the above information is
y F correct.1 agree to comply with all city and county ordinances and atom lows relating to
V building construction,and hereby auNorim rcpremmativer of this city to enter upon the
Uabove-mentioned properly for inspection purposes.
-, (We-)agar.to save,indemnify and keep harmless Ne City of Cupertino against
cA) Iiabi ies,judgments.costs and expenses which may in any way accmc against mid City O N�
J Z in co ucnecofthc rant goflhispermil. v//
" APP CANT NO T DS A Y-WITH ALL NOWPOINT Issued by: Date j
SOU ERG L
Re-roofs
igna re-o Applice "ComHAZARDOUchoS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future Wilding occupant atom or handle h nodous materiel
ss fined by IW Cupertino Municipal Code.Chapter 9.12.and IW Health end Safety
e.Section 255124)? All roofs shall be inspected prior to an roofing material being
Ayes g� p p y g g installed.
will the applicant or future building meupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
at hazardous air contaminants as defined by the Bay Arca Air Quality Management all ne materials for inspection.
Dtxuict?
D Ycs
1 have arad thc hmWiwsmaudals mquimmcnu under Clupur6.95 of the Califor-
nia alth&Safety tions25505,75575and2553a.IundenrandthaiftheWilding to-�gro3
J of cu rely a e oink Na it u m iality m many tic o-cupans of the
rcyu men wni s mel issanccofaCcrdficauOfOccupancy. Sig at eo Applicant Date
0'01&Y73 All roof coverings to be Class"B"or better
cru authomcd agent Date
CITY OF CUPERTINO 03 ( o CD ( �
REPIPE/SEWERS/MAIN SERVICE
cuPE�TiNo PERMIT APPLICATION FORM
APN# ' 2l 6 Date:
Building Address: �j
Owner's Name: Phone#:
i
ContractorPhone: License #:
eaT �t S So ► a6�
Contact: '/� Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb LN'
Job Description:
Residenti ommercial ❑
Cost of Project:
Qty. if
,,4ppVc-pNe Fee ID Fee Description Fee Group
PPERMTTFEE Plumbin.g 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
W
�d. 8