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09020065 CTTY OFC]PERTINO RA BUILDING DIVISION PERMIT �1' TRt� Q �11ATIf3 PERMIT NO. BUILDING ADDRESS: 10141 C LBY BAY AREA RE P ISSUE DATE OWNER'S NAME: 89 -$ S A CONTROL NO. PHON (4 0 8) 371 -576 3 BUILDING PERMIT INFO ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 0 00 C LICENSED CONTRACTOR'S DECLARATION Job Description v I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Code and my license is COPPER RE-PIPE HSE, WTR H ETR RE PLCMNT & WATER MN �H in full force and eft Ig Z License Class Contractor -y Date RCHITECT'S DEC1A ATI N I understand my plans shall be used as public records me D U `o H Licensed Professional OWNER-BUILDER DECLARATION I hereby alTirm 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 improve,dcmolich,or repair any structure which requires a permit to construct,alter, rn prior to its issuance,also requires the applicant for such permit to file a signed statement gq,Ft.Floor Area Valuation -Z< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Fy F G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $6000 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). 3 162 8 04:6 . 00 ❑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 Required Inspections 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 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<aw' ❑1 am exempt under SeB&P C for this reason Sec. 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 Worker's Compen- in,as provided for by Section 3700 of the Labor Code,for the performance of the ,.urk for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the pe rmance of the work for which this permit is issued. My Workers oto ens 'n Insu a carrier and Policy number are: Cartier. ✓ Polity No.: CERTIFICATE OF EXEMFIION FRO WORKERS' 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,l 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 F~.t CA 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 Q Lender's Name � Lender's Address Z V 0 I certify that I have read this application and state that the above information is GL 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 W above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against to liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the grand f is permit. Date APPLIC D WILL COMPLY WITH ALL NON-P INT Issued t y: S O S ' 6 Re-roof iA Signature Applican Contractor a 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 s shall be inspected prior to any roofing material being installed. ❑Yes N. If a roo r is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which ,it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. vitt? ❑Yes 1 have read the hazard us mate' s requirements under Chapter 6.95 of the Califor- nia Health&Safcty C 25 .25533 and 25534.1 understand that if the building docs not cu a e 4th nsibility to notify the occupant of the Date reyui rats rc t r uance o to of Occup $ignatU-e of Applicant 3 a All roof coverings to be Class'W'or better Owner or - Da �q pop low CITY OF CUPERTINO r , REPIPE/SEWER/MAIN SERVICE CUPEiZTINO PERMIT APPLICATION FORM APN# Dat Building Address: /D l l f� Own�e 's�e: Phone 2S � _3� ,7 —� t,h L) Contrac r: Phone#: �4 Fax#: Contact: Phone#: 0 IN Fax #: 43 Contractor License#: �'� �3 Co Cupertino Business icense Job Description: Cc Residential Commercial ❑ Valuatio L% Project Size: Express ❑ Standard Large 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 r,,--pipe per fixture P ICPRP I PGASCOM Commercial Gas Piping System P — 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CITYCUPEF�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sew-r 1PRREPIPE Residential re-pipe per fixture P HURT t/ 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Di,3posal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Pining System P 1-4 Outlets 1BPGAS Gas Piping Systerr. 5+ Outlets P 1 PPERMITFEE Plumbing Permit fee Issuance P 1PLMBLNCK Plumbing Plan Ch.-ck P 1 PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1 BUSLIC Business License B f �- Community Development 10300 Torre Avenue Zvi Cupertino CA 95014 Telephone(408)777-3228 aft OF Fax(408)777-3333 ,UPEkTINO Buildi.n De artment JOB ADDRESS: PERMIT # OWNER'S NAME: b°L wt v PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: S_gnature Date Please check applicable subcontractors and corr plete the following information: SUBCONTRACTOR BUSI NTESS 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