07010100CITY OF CUYLxlury
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
I OWNER'S NAME:
TOM HALL
HONE:
rwithSection ECT /ENGINEER:
p ZO LICENSED CONTRACTOR'S DECLARATION
w hereby affirm that I am licensed under provisions of Chapter 9 (commencing
c Z 7000) of Division 3 of the Business and Professions Code, and my license is
t. and off j v� z Lic. N 3 p c
COntrac'^- „ ul ARCHITECTS DECLARATION
a-r 1 understand my plans shall be used as public records
�yU
L w rt„ Licensed Professional
o ` OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
cc following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any structure
y " y prior to its issuance, also requires the applicant for such permit to rile a signed statement
- Z < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
YF (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicat to a civil penalty of
not more than five hundred dollars ($500).
❑ I, 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 (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
rc
own employees, provided that such improvements a 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-
who c contracts r such projects ts an owner of with a contractor(s) I who builds or
licensed pursuant the Contractor's
License Law. B & P C for this reason
❑ I am exempt under Sec.
Owner Date
WORKER'S COMPENSATION DECLARATION
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356 MATHEW STEET
(408) 727 -9850
PERMIT NO.
SANITARY NO. CONTROL NO,
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
INSTALL LATERAL CLEAN OUT
CHEROKEE CONSTRUCTION RENEWED BL 1/30/07
5q. Ft. Floor Area
3750600"
I hereby affirm under penalty of perjury one of the following declarations:
] 1 have and will maintain a Certificate of Consent to self -insurc for Workcr s Compcn-
Ltion, as provided for by Section 3700 of the Labor Code, for the performance of the
ark for which this permit is issued.
] I have and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
Iy Workers CompeLnsa,.dn limrance carrier and Policy numb 4=:
r.
;arrie
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not he completed if the permit is formic hundred dollars ($100)
rc less.)
certify that in the performance of the work for which this permit is issued. I shall not
:mploy any person in any manor so as to become subject to the Workers' Compensation
aws of California. Date
4pplicant
VOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
accome subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO(iR�EREGULAT�10`NS.
_
Signature of Applicam/Contra'0' Date
HAZARDOUS MATERIALS DISCLOSURE
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 Safcty
Code, Section 25532(a)?
❑ Yes ff<O
Will the applicant or future building occupant use equipment or devices which
emit hazardous at contaminants as defined by the Bay Area Air Quality Management
District?
p Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
rcquirc is which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent 1ate
Issued b
Re -roof:
Type of Roof
Valuation
$5500
Occupancy Type
Required Inspections
SANITARY
l
�tlE71C1,�,
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signatu -e of Applicant
All roof coverings to be Class "B" or better
Date
CITY OF
"UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777 -3228
Fax (408) 777 -3333
Building Department
JOB ADDRESS:
r1le-ele
PERMIT #
,70 (el(y c
rti
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OWNER'S NAME: a r••y ' (A �J-
PHONE # 72 2 -7 , j
GENERAL CONTRACTOR: C6ito(C are_ Cc,12, ,
FAX #
I am not using any subcontractors: �u (3 O 4 %
E ignature Date
Please check applicable subcontractors and con iplete the following information:
Owner/ ontractor igna Date
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/ ontractor igna Date
CI F.
CUPEI,TINO
CITY OF CUPERTINO
REPIPE /SE ' 1=EJZS /MAIN SERVICE
PERMIT APPLICATION FORM
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BPERMFEE
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Bui di g Address:
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BPGAS
Ownerlame:
PLUMBING
Phone #:
Co r ctor:
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Phone:
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License #:
Contact:
,1vNA
Phone:
Cupertino Business License #:
Building Permit Info:
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BPWSVCS
Residential ❑
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Cost of Project:
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Applicable Fee ID
Fee Description
Fee Group
BPERMFEE
:31dg. Permit Fees
BUILDING
BPGAS
,3as Piping System Fee
PLUMBING
PPERMITFEE
:'lumbing Permit Issuance
PLUMBING
BPREPIPE
:tepipe of Fixtures
PLUMBING
BPFIXTURE
:'blg. Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
viewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License I
BUILDING