07010079 CITY OF CUPERTINOrT
BUILDING DIVISION PERMIT OR 1NMT�QN'.�
PERMIT NO.
BUILDING ADDRESS:
45 CUPERTINO RD # 41 _J__BZS_I.DENTZA1,- 0:70100:79 LSSUE DATE
OWNER'S NAME: C,��7 rT r�r
SUNNY VIEW MANOR 1479 BERGER DR 01/12/2007
SANITARY NO. CONTROL NO.
,ONE:
(408) 287-2165
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
4 U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z�
with Section7000)ofDivision3oflheBusinessandProfessions Code,and mylicenscis REPLACE SEWER LINE WITH TRENCHLESS TECH
y in full force and effect.
7&5"1
j,n? License Class Lic,i
aka Dateri�-v7 Contractor 4'ui
ARCHITECT'S DECLARA71ON
2.4
U l understand my plans shall be used as public records
a
Lin Licensed Professional
j.1 OWNER-BUILDER DECLARATION
f 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
%p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
K$ which requires a permit to construct,alter,improve,demolish,or repair any structure
n Z r prior to its issuance,also requires the applicant for such permit to file a signed statement $q Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
$15 9 9 5
xF= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 5 drat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 32615013 Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dots not apply to an owner of
property who builds or improves thereon,and who does such work himself ar through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License taw.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workees Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation to mance carrier and Policy number am:
Carrier. 4,., e t?al / Policy No.: 0 j�; D
CERTIFICATE EXEMPTION FROM WORKE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California.Date—
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J',Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
Hrte. 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0Z
Lender's Address
U Q 1 certify that I have read this application and state that the above information is
w F correct I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permiL Date
r-+ APPLICANT U ANDS iLL MPLY WITH ALL NON-POINT Issued by:
SOUR TIONS.
Re-roof:
Signature ol'Applicaritt0ilefEtor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
❑Yes
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
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? /
❑Yes [afVu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently haves tenant my responsibility m notify the occupant of the
rcyaire ch mastbc taissuance oracenificatcarOc O% ccupancy. Signature of Applicant Date
-a All roof coverings to be Class"B"or better
Owner of authorized ag nt Date"
Community Development
10300 Torre Avenue
aa
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
Cu c6 ; _ 070�0 0 "7 �
OWNER'S N 'QLCA) r" -0 4. PHONE # �;--
GENERAL CONTRACTORa�-�- FAX # yv _ G�-
I am not using any subcontractors: /-/� 7
c-ignature Date
Please check applicable subcontractors and complete the following information:
60 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 CUPERTINO V9
11 REPIPE/SERV 11S/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # M b'n Date: '
Building Address:
Owner's Name. Phone#:
Contractor: 0 Phone: License#:
}� or -76-1-
y _53
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
kQLc G u.e, uldr_(,Vkklle5 lc c
Residential ❑ Commercial J2"
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE .3ldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE :dumbing Permit Issuance PLUMBING
BPREPIPE :Ze ipe of Fixtures PLUMBING
BPFIXTURE :'blg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC 3usiness License BUILDING