08120037 CITY OF CUPERTINO
BUILDING DIVISION PE CO'N=TR:4CT®12ANI`'ORMATIONr
BUILDING ADDRESS: PERMIT NO.
917 OLD TOWN CT JM DRAIN CLEANING AND nRj ?onvz
OWNER'S NAME: PLUMBING PERMIT ISSUE DATE
NE: A CONTROL 10.
(408) 903-8184
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMBo MECH
0 0 t�
no, LICENSED CONTRACTOR'S DECLARATION Ib Description
rd ux 1 barratry affirm ala.1 am licensed under poormors of chapter 9(mm
meKOeSCTIp
ing
n?Nwire Sectim7OW)of DivWon5afdc Buunevarm Professions Code,andm,as,aeis
? mm�fomeMe COPPER RE-PIPE FRM HSE SHUT-OFF TO ENTIRE HSE
j n Z Licence a R
u I;,qq Dao - GAS'DF L
` 'N RCHIIECTS DEC
(L 77 I uMenuml my Plan shall be used an public rtcortls
JyU
Uccnmd Profcsuonel
u v,5OWNER,BUIL.DER DECLARATION
1 hereby a f.that I am exempt from the Contractors License,Law for tc
O O fe llowi,minae.(Secdaa 703 1.5,Basin.and Proresuons Code:Any city or county
$ which acquires a permit in cmuwct,alar. mprone,demolish,or repair my structure
_Zy prim to its issuance.also acquires to applicant far such permit to file a signed usammn
E O that is licensed pennant a the provisions of the contractor,License Law(Chapmr 9 Sq.FL.Floor Area Valuation
zgQ (commencing wit Section 7000)of Division S of to Pronasions
Busirom and Code)or
jt — tat h u exempt meafrmn and the buts for the allcged exemption.Any violation of $7552
Section 7051.5 by any applimi for a Permit subjects to appl4ant to a civil penalty of APN Number Occupancy Type
rot tome than five hundred dollar 35611034 . 00
❑I,u awrcs of the property.m mY wployns wit cages u teen m4 tmmpewtim,
Anddo mewent andmeue Como re,Lacosor ave,dos out A(See.II W.Buuross
And eProf..nywh obu carie:The Contrutoh Lieu Law,does out apply lf rt owmr m Required Inspections
propertylobo builds viimphasesen impr wer who doessuch wink Mntselfter trough his
than employees.cueK,provided i Natsuch impro id cras within
amnosim
dmpletied for algin-
however,to amidine ter i errs of panmt u sold within one year of imprown fe,to owner-
buil4r will haw tie Wrdrss or proving mat k did not build a improve for pugoa of
x4.7.
El 1,As ower of the property.w exelusiwly contracting with linnscd com unces to
mrstruct me Micah(Sec.7044,Business and PmfesuOK Cade:)The Cmuactors U.
cause law does not apply as an owner of properly who builds or improves thereon.and,
who controls for such projects with.cmtrutor(a)licensed pursuant to On,Conlrutars
License Law. _
❑l am exempt uncle See ,B B PC for to moron
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby elsm under penalty of perjury,one of tic following declarations:
haw and will maintain a Cmifiuu of Conant to self-insure far workers Coupon,
sats acdl far by Section 1TOo of the Labor Code.far to perfama a of the
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700af do labor Cade.for the Kdarmarccedo wank for which this permit is issued. '
My WorkeYs Compensa lm hwrame curies and Policy number am: nn Sys -
Cartier. �_Paliry No._ QQ X
TIFICA O EXEMPTION �IA/ sell
FROM WORKERS'
COMPENSATION INSURANCE
Ina seetim need mtMcampleeti If the permit B far.hundred dollars(SIM)
or less)
1 msufy mat in the pe mar.of to cask fm which this Permit B issued.l"I rot
employ say person in my manrcr An As to beeumc subject n the WmkerYCompmou. - -
Laws of California Dae
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
Wcome subjau to the Workers Compensation pmvisioK of tM Labor Code.you muss
wJ O formwit i comply win such prewima a this permit shall be deemed mooted.
zCONSTRUCTION LENDING AGENCY
(r ice. I hemhy affirm to mere iso concentration landing Agency tar the pedumamce
C! the wink for which this permit is Lssued(Sec.5097,Civ.C.)
Q Lenders Name
Z lenders Address -
U O 1 certify mat 1 have mul this appreadW and sue to the above nform,tim 4
fi.E tomm l agree to comply with all city and county ordinances and sure laws relating to
.l7 building construction,And hereby authoda repreemutives oftis city to enter upon to
alewmrntiuned property for inspection purposes
(We)agree to an.indemnify and keep bamless the City of Cupertino agdnst
In Iiabilitin,JodLmenls.cKlsaMexpe....whichmaymanyw'ayacmeKaleaailCily
U z APPo CgANT UNDERSTANDSf Au mrLL COMPLY WITH ALL NON-P INT
SOUIssued by:- Date
R ULAT1
- Re-roofs
pelt HAZARDOUS MATERIALS DISCLOSURE Dae Type of Roof �-
Will the applicant or future building accupmta m or handle harardots material
as defined by the Cupertino Municipal Coda.Chapter 9.11.and to Health and Sefely
Code.Section 255524)7 IAll roofs shall be inspected prior to any roofing material being installed.
❑res /
ce
Will to applicant m forum building=up..,use equipment ter device which If a roof is installed without first obtaining an inspection,I agree to remove
iWil hvsNnus air covuminanls As dersed by the Bay Ann Air Quality Management all new materials for inspection.
Atosuite? (�
❑Yes O -
`
I haw and the haamous muerialsrequiremenuumk:r Chapterb.95 of the Califor-
nia Health h SafmyCode,Saves,155(15.25533 arul M514.1 wmerwum thuifthe Wilding ,
does rot eurmndy haw a teKnl dual my msponsihility a mtifY tc o ,of tic
oxmi hahm me mom of aCanlficeteofOccupamp Signature of Applicant Date
El
ora ori a Dae'
All roof coverings to be Class'RA'or better
Community Development
10300 Torre Avenue
F / Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
W-UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
Ds(26��
OWNER'S NAME:M (Q. 1 PHONE #
GENERAL CONTRACTOR• - FAX
I am not using any subcontractors: Z-
i ature Date
Please check applicable subcontractor 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
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
06 �D�7
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # 0 Date:
Building Address:
Owner's Name: Phone #:
S Q
Contractor: Phone : ��/�� ��
1 ,
C 3
Fax #:
Contact: hone#:, �(� L/
Fax #:
ontractor License#: 8 -7 2
Cupertino Business License#:
Job Description: C, f/ >; 1 fc, T ro p '
TO o� ..se. '
ld'Residential Commercial ❑
Valuation:
.SS
Project Size: xpress Standard ❑ Large ET Major
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
IPRSEWER Residential building P 1RPSS
sewer/sanitary sewer
CITY OF CUPERTINO
L�e��" REPIPE/SEWER/MAIN SERVICE
CITY OF
CUPERTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
j Group
IPRREPIPE Io• Residential re-pipe per fixture P 1RPRP
1BPWSVCS ao Water Service P 1CPWS or
1RPWS
IPPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P •
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel &Documentation Fee B
1BUSLIC Business License B
Revised 6-16-08
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