04010100 (2) CITY OF CUPERTINO '
BUILDING DIVISION PERMIT ,CONTRACTC7RINFQRMA_KJON:
• BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO04010100
OWNER'S NAME: PERMIT LSUE DATE
EDISON FON
ONE;
SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHG EC(ENGINEER: UILDING PERMIT INFO
BLDG �Ba�L' PLUMB MECH
38p LICENSED CONTRACTOR'S DECLARATION
ZC I hereby affirm that I am licensed under provisions of Chapter 9(commencing - Job Description ✓'4
<U with Section 7")of Diviaion3 of the Business and Professions Code,and my license is
�„ in full force andcffen. � Leg L�2G COPPER REPIPE �2Qy
qz Licensed a .. 2
gF,o Data T*!iD CL I& 1301
9Q� ARCHITECTS OECLARA ON - !s(
a� I undersnnJ my plans shall be used as public rccnrJs
JyU
;in Licensed Pmfc3sinnal
S OWNER-BUILDER DECLARATION
ComraON
E a E 1 resio affirm on 1 1. exempt from the Cssions o License Law for the '
m
which
uiresa(Section 7onstr Busino, and Professions Code:Any city or county
which its requires issuance,permit re cores the,altopplic improve,dcmrilb�hh penmen fi repair any taructure
tement
that heor itsensed pursuant
the applicant forthe sucContractor's
ice a,Lawned mhaptert nnn
yo (comm islicensedwith
Section 7 the)of Divines of the the Bincros.rd enselsw(C Code)or Sq.Ft. Floor Area Valuation
H (cat he
(commencing SmaVons and m basis far
of the Businessand Professions Cn�Qof
$ Net he a exempt therefrom entl Ne buffs for the alleged cxempuon.Any violation of
Section 70313 by any applicant for a permit subjects Ne applicant to a civil Penalty of 3%73304illeS O 0 Occupancy Type
not more than Eve hundred dollars($500).
❑1,u owner of the pmperty,or my employees with wages u their sola compensation,
will do the weirs and the sW=IYm is not imendCd or offered for sale(Sec.70 ,Business Required Ins actions
and Professions Code:The Contracmr's License Law does not apply to m owner ofp
pmpeny who builds or improves thereon.and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale,IL
however,the building or improvement is sold within one year of completion.the owner.
builder will haw the buNen of proving Net he did not build or improve for purpose of
.In.).
❑h as owner of the property,am exclusively comncting with licensed contractors to _
consumer the pmject(Sec.70,14,Business and Professions Cade:)The Contractor's U.
acme law does not apply aro an owner of property who builds or improves themon,and
who contracts for such projects with a consio or(s)liunsed pursuant to Ne Contractor"
License Law.
1 em arempu under Sec. .B&P C far this reason
1371M
ner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declentions:
1 have and will maintain a Certificate of Consent to self-insum for Workers Compere
u provided for by Section 3700 of Ne Letter Code.for the performance of the
k for which this Permit is issued.
I have and will maintain Workers Compensation Insurance,u required by Section
of the labor Code,for the performance of the work for which Nis panni,is issued.
Workers pmPmtsmimi once ctvier and Policy number amrier. S -e V7 o` Policy No.:6 00-7L b W
CERTIFICA OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE
(This section need not becompleted if the Permit is for one hundred dollars(5101)
or less)
I certify Nat in the performance of the work for which this permit is issued,1 shall not
employ any person in any mannerso u to become subject o the Workers'Compensa0on..
Laws cf California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenificoe of Exemption,you should
become mhjeet to the Worker's Compensation previsions of the Labor Code.you must
.J z forthwith comply with such Previsions or this permit shall he ticcmed mvokcd.
z rte~. CONSTRUCTION LENDING AGENCY
[—r I hereby affirm that there is a construction lending agency for the performance of
Cli > Ne work for which this permit is issued(Sm.3097,Civ.C.)
W
Leader's Name
� Q
is z Lender's Address
U Q I choir,Nn I have read this application and sum Our the above information is
u, (~ correct I agree to comply with all city and county ordinances and state laws relating I.C V building construction,and hereby amhorim representative of this city to enter open the
elwve-mentioned property for inspection purposes.
W
(WcI agree7q save,in�ammfy and ke harmless the City of Cupenino egeinn 4-?h liabilit7u,judgm�.mas)ndepcnsesw-hmaymmywayacervcagainstaaid Cdy
V 7 in conseq rte 6666f the 8r 6tin6 of his Per u.
r7 APPLI U E STAN AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
EGDR. G
Re-roofs
rc of ApplicaHAZARDOhric"rS ,ERI SDISCLOSURE„ Dem Type of Roof
Will Nc applicmtm future building dupanl store or handle horardous material
u fined by the Cupeninq Municoipal Code,Chapter 9.12,and the Health and Safety
edr.Section zss3z(a)?
❑Yeas \/�_„p All roofs shall be inspectedprior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is.installed without first obtaining an inspection,I agree to remove
it havardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
istricG
❑Yes, •�u '
I '' r' ,see, mater41a
ndar Chapthr 6.95 of the Calding
nix
He & cry �,SccJ 2x5d NatiThuilJingt ty, avem M, ity b nodl'yNcoccupantofilia
•sear purrmatmor =uPmcy. Signature of Applicant Date
�.
w cr ser amhmimd agent Datm - - All roof coverings to be Class"B" or better
CITY OF CUPERTINO d
' REPIPE/SEWERS/MAIN SERVICE
IT F
CUPERTINO PERMIT APPLICATION FORM\
APN# �`7 1 • b. Date:
Building Address:
Owner's Name: LI , s -H C15
Contractor: Pone: License#:
lno ban * �� ��, 2L4,qoS
Contact: Phone- Cupertino Business License#:
Card I a �v��
Bud ding ermit Info: /
Bld Elect E3 Plumb L9'
escription:
Residential" Commercial ❑
Cost of Project: OGD
•
Qty. if
Applie Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permdt Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING