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07050053 CITY OF CUPERTINO BUILDING DI' ISION PERMITT . � } t�i'Z'IQ ' PERMIT NO. BU"'M9.4pRb" RESTON DR DRAIN DOCTOR 07050053 l U 4 11 U C PERMIT ISSUE DATE OWNER'S NAME: OLKEIN DOUGLAS E AND ROCK 1775 WINCHESTER BLVD 05/08/2007 )N SANITARY NO. CONTROL NO. (408) 370-3()82 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH i p C LICENSED CONTRACTOR'S DECLARATION Job Description Ur 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z r with Section 7000)of Division 3 of the Business and Professions Code.and my license is * NO C OND I..'IONS H infull force and eff ? License Class Lie.i E w Date AR HITECTC S D RA 7 < 1 understand my plans shall he used as public records )yU a 1- Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the zp O following reason.(Section 7031.5,Business and Professions Code:Any city or county ,=, which requires a permit to conswct.alter•improve,demolish,or repair any structure o Zprior to its issuance,also requires the applicant for such permit to rile a signed statement o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.FI.Floor Area Valuation e (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $33000 u R F 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 applicant to a civil penalty of 32 637053 AffiNumber 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 is not intended or offered for sale(Sec.7044,Business "Required Ins ections and Professions Code:The Contractor's License Law does not apply to an owner of p 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.). ❑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 U- 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 Contractors License Law. ❑I 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: ❑I have and will maintain a Certificate of Consent to self-insure for Workers 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 Workces 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 Insurance carrier and Policy number are: Carie: rlif N1f1Cf4rti✓nicy CERTIFICATE EXEMPTION FROM KERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workeri 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 I hereby affirm that there is a construction lending agency for the performance of !x the work for which this permit is issued(See.3097,Civ.C.) W Q Lender's Name z Lcoder's Address U 0 I certify that 1 have read this application and state that the above information is (L " correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction.and hereby authorize representatives of this city to enter upon the a ahove-mentioned property for inspection purposes. f\\` (We)agree to save,indemnify and keep harmless the City of Cupertino against U11 liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ►'� -POINT Issued by: Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON SOURCE REGU IO CQd&O q Re-roofs t Sig nt/Contractor 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)7 All roofs shall ie inspected prior to any roofing material being installed. ❑Yes b No 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materia 1S for inspection. District? ❑Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the requirements whit irmetcuss e�rtce of a Certificate of occupancy. Signature of Applicant Date C S208/d n. All roof coverings to be Class"B"or better Owner illauthorlized agent Date' CITY OF CUPERTINO REPIPE/S W . S/:!MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # Date: Building Address: thLcz Owner's Name: Phone#: Contractor Phone: License#: Contact: Phone: Cupertino 6 �ne�ssLic�ense#: Building ermit I o: / Bldg 19 Elect ❑ Plumb LsJ/ Job Description: Q01A Residential Commercial ❑ Cost of Project: , Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILDING BPGAS Gas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re Lpe of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Mair. Water Service PLUMBING BPSEWER Sewf;rs PLUMBING BPSEWAGE Sew<<ge Disposal PLUMBING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Cl- OF Fax(408)777-3333 'UPEkTINO Buil din r Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 05 Gb ion. Signatsre Date Please check applicable subcontractors and com lete 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 er/Contractor Signature Date