04010079 (2) CIT
OF CUPERTINO ® - o `'` �t^)r' 3•
BUILDING DIVISION PERMIT CON?TRACTOI2�INkORMATION "
. , ,. ;
BUR.DINGADDRESS: AQUATEK PLUMBING INC PERMITNO04010079
OWNER'S NAME: PERMIT ISSUE DATE '
JOHN BRUZUZ
10,NE: SANITARY NO. CONTROL NO.
(408) 295-7767
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
so F 1 nem6y alarm that 1 am licensed under provision of Chapter v(commencing Job Description
�ZrOst with Sc tion g10)uf Divixion3 o(mc 8usincq aid Pm(cssinn.Code,and myliccn.is
.n6L In full( def t. �j
5'p,?, Licen , �`'�Lic.a 6-1-1 5-n -1 REPIPE & WATER MAIN � '
��,❑ Dam Contac r PINALED
e¢¢ HITE 6 DEC "ATION
y 2 1 untie Man hall be use s I'c r -—
LicensedPod - nal 52004 Q g�,atg
NEN-BUILDER DECLARATION FEB 5 2®U4'
hereby (firm that 1 am exempt from the Cnnuenars License Lew for the
y00 following reason, cede IIJLS,Business and ProfcssiomCrdc:Any city nr courtly
m which roouirci a permit m construct,alter,improve,demolish,m repair any structure
prior to its issuance.also requires the applicant for such Permit to file a signed statement 01110 r%sigilasakcc;nnn
ZQ that he is licensed pumantmtheprovisinnsnfoaConuactur'sLima.Law(Cm1rel9 Sq. Ft.Floor Area tion
$ (cmemencingwith SCedmill 10)of Division 3 afthe Businessand Professions Code)or
met he is exempt metefrom and the basis for the alleged similar.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3ETD13`i"cr00 Occupancy Type
not mom man Eve hundred donars(6500). P Y YP
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale 7040,Business Required Inspections
and Profusions Code:The Contractor's Licen.Law does not apply to an owner of 9 P
propeny who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended oroRered forsale.If,
however,Ne building or improvement is sold within one year of completion,me owner.
builder will have mm burden of proving that be did not build or improve for purpose of
.I,J.
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7040,Business and Professions Code:)The ConRactor'a Li.
cense law does not apply m an owner of property who builds or improve Ih.mon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors _
License law.
El I am..emit under Sec. B&P C for nth reason -
Owner Data
c" WORKER'S COMPENSATIONDECLARATION
I hereby affirm under penalty of perjury one of me following declarations:
have and will maintain a Cenificote of Consent sell-ieum for Worker's Compos
on.as provided for by Section 37M of me Labor Code.for the performance of the
work for which this permit is issued
1 have and will maintain Worker's Compensation Imurancc,as required by Section
J700 of me Labor Code,for the performance of the work for which this permit is issued.
My WorkcS Cnm enmtion lnsunnoe camicrend Policy rnumber am: � [sem
mer: ! Policy No.:n.L�y3t� 4v'
CBRTIFIC% F Pr10N FROM WORKERS' -
COM ENSATION INSURANCE
(Thu suction nccd nolhecomplemd if the permit i.far one hundred dmllam(g IBI)
or less)
1 certify that in the performance of the work for which this permit is issued.l shall not
employ any person in any manner.as m hecome subject to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of E.cmption,you should
become subject b the Worker's Compcnsuion previsions of me labor Code,you must
,J z forthwith comply with Such ocrisinus or this permit shall be decreed revoked.
'ZO CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
f1, the work for which this permit is Word(Su.3097,Co,C.)
W� Q Lender's Name
D z Lender's Add..
V C) I certify that 1 have read this application and sum that he above information is
Ur H correct.I agree to comply with all city and county oNinances and Sum laws relating to
Qv
building construction,and hereby aummim representatives of this city to enter upon the
W above-mentioned property far inspection purposes.
APAI�NT
)agree to aave,indemnify end keep harmless the City of C.Penirm against
f..r In hIgmcu .c suendespcnse which may in anyway&cc=against said City
V z ncc oft ling of this permit.
UND TA or AND WILL COMPLY WITH ALL NON POINT Issuedby: Date CODCUL
i \S. o Re-roofs
S t Applicen omrDOT Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wi y the C.Nnin.nt or Medauture building Co e.Chapter
9.1 or handle Health
material
as defined by the Cupertino Municipal Cada.Chapter 9.12,end the Health and Safety
ode,Section 25532(.)? / A 1 roofs hall be inspected prior to any roofing material being installed.
❑Ye. a No
Will the applicant or future building occupant use equipment or devices which If a oof ii installed without first obtaining an inspection,I agree to remove
ha=dnus air contaminants a defined by the Bay Area Air Quality Management all n Ip rials for ins CtlOn.
in? ,�
C]Yes t]Nt ,
a me ha nus materials requirements under Chapter 6.95 of the Califon
d�.Imi
I Code, dons 25505.35533 and 2550.1 understand that if the building '
0 have a ani Nat iI is respon ihih Idty the occupant of the/n on as,,be prior iss cc ofe cam of oicury. Slg toren ppI rat Dille
✓ Owner sumo zed I S p� All.r coverings to be Class"B"Or better -
CITY OF CUPERTINO
CU
REPIPE/SEWERS/MAIN SERVICE a
S CUPERTINO PERMIT APPLICATION FORM
APN# a� a 33 1
Date:
I - IS • Zoota
Building Address: c
°0.Z 8�2 R,- Wc,\r\vv
Owner's Name: Phone#:
Oht1 �j�UZ�Z 408 400 4235,
Cont tor: Phone: License#:
l CkV6L 4U8 9g5 __ql 67) �, __T_ 5 -9 �
Contact: Phone: Cupertino Business License#:
Derrec.V. S201
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: n
CT- K•<. \�O-� p r�C,. l.��ai'cr' YT�G�\r'1 ,
Residential ❑ Commercial ❑
Cost of Project: -000 00
Qty. if
A licable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFD(TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING