07010110 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
-co. �CQR IQRMtTI�N.�
PERMIT NO.
BUILDING ADDRESS:
TE
OWNER'S NAME:
SCOTT HUGHES 1020 RUFF DR 01/18/2007
SANITARY NO. CONTROL NO.
TONE:
(408) 377-9990
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
a o 0 0
J 0 a LICENSED CONTRACTOR'S DECLARATION Job Description
4 u E- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
4ZuVJ with Section7000)ofDivision3oftheBusinessandProfessionsCode,andmylicenseis INSTALLATION OF PROPERTY LINE CLEANOUT
e H in full force and effect (,/� 7 7
j Z? License CI _.__L _�•
E-p Datc Contractor
ARCHITECTS DECLAR TION
C` 1 unders and my plans shall be used az public records
:) U
In.
U.H Licensed Professional
O<
OWNER-BUILDER DECLARATION
n v1�
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county
y'.� which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to rile a sighed statementFt.Floor Area Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq $2500
zF (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 violadon of �,p� Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 35906043 .•ty'l1' Number
not more than five hundred dollars(5500).
❑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(Sec.70",Business Required Inspections
and Professions Code:The Contractor'sLicense Law does not apply to an owner of
property 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.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.).
❑I,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 Law.
C3I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worked ornpensatigy Inwraga carrier and Policy number are:
Carrier. rl��'La-'_: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 100)
^
Icss.)
I certify that in the performance of the work for which this permit is issued,1 shall not
e
employ any person in any manner so az 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z. CONSTRUCTION LENDING AGENCY
E~t off. I 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 A Lender's Name
aLcndces Address
I certify that 1 have read this application and state that the above information is
U
o- correct.I agree to comply with all city and county ordinances and state laws relating to
rJ 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
,E liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. Date
1— APPLICANT UNDERSTANDS
AND WILL COMPLY WITH ALL NON-POINT Issued f y:
SOU RTIONS
v_
�frr4�'ab Re-roofs
Signature of Appl' ontractor D
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)? IN
All root's shall be inspected prior to any roofing material being installed.
❑Yes oWill the applicant. building occupant use equipment or devices which
If a zoo�is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑YesNu ^ '
1 have read the hazy/ousaterials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building v
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requi en which must be met prior to issuance of a Certificate of Occu �r. S ignatu re of plicant Da e
• /$ y All roof coverings to be Class"B"or better
Owner or auth zed agent Dare
Community Development
10300 Torre Avenue
"Its
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
'UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: Yc, ha44J PHONE # 77.7
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
;nature D to
_4Aa
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
FEiLathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
tooCITY OF CUPERTINO
REPIPENE iE.U.S/M.AIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
775--2 .
Phone#: 6 2 _ �
�,
Owner's Namu e:
S'c a~t`f h k.c � 81
Contractor: Phone: License#:6 71�//5
Contact: Phone: Cupertino Business License#:
Chew z
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
14* 114,4i'Ll
Residential_o' Commercial ❑
Cost of Project: 2 a�
Qty. if
Applicable_ Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Sas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE lie i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING