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09020044 7Y0 F CUPERTINOILDING DIvIS10N PERMIT PF-RMrr NO. BUILDING ADDRESS: 21061 GARDENA T R MARY J1.NE P I ZA PERMIT LSSUE DATE OWNER'S NAME: r R V JANE D T Z A, e ft�A CONTROL NO. ')NE: BUILDING PERMIT INFO ARCHITEGTIENGINEER: BLDG ELECT PLUMB MECH u p p LICENSED CONTRACTOR'S DECLARATION Job Description UE I hereby affirm that I am licensed under provisions of Chapter 9(commencing z m with Section 7000)of Division 3 of the Business and Professions Code.and my license is REPAIR BRKN 411 0 MAIN SWR LINE o�y in full force and effect. n� License Class Contractor 3 F•p Date ARCHITECTS DECLARATION J g<1 understand my plans shall be used as public records �yU O I- Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm 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 e m Pi which requires a permit to construct.alter,improve,demolish,or repair any structure 4—In prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation Ic that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. YF$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $500 y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of not mere than five hundred dollars(M). 32608035 . 01 ❑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 safe(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law dors 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.). N10TARY Grf 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. ❑I am!�Mm);kC__ B&P C for this reason SA Owner Date ENSATION 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- .,anon,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 Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he 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,I shall not employ any person in any manner so as to bec me sac 'ect to the Workers'Compensation Laws of California.Date Q 99 Applicant — NOTICE TO APPLICA r making this Certificate of Excmpuon,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J. `j--, forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY F~•r►�.r I hereby affirm that there is a construction lending agency for the performance of - p(, the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name 0 Lender's Address 1 certify that 1 have read this application and state that the above information is UTr H 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 liabilities,judgments,costs and expenses which may in any way accrue against said City P� / V Z in consequence of the granting of this permit. Date /' ( �y S r•-e APPLICANT UNDERSTJWDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SO d� Re-roo?,s — Signaturc fApplicanUContrector 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 Cede,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes VMe If a rocf is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which .hazardous air contaminants as defined by the Bay Area Air Quality Man all new materials for inspection. .strict? ❑Yes I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building docs not currently have a tenant.that it is my responsibility to notify the occupant of the req„ uSt be t or ance of it Ccrifrcaic of pan . Signatt re of Applicant Date cirl All roof coverings to be Class" `'or better D Owner or orixcd agent au: D 7 U ;� 0"I CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# 3 0 © � Date: z Building Address: 216 I CAz-C29--JA TSL. . Owner's Name: Phone#: M� 9—e —3;kc� n—2�zizC) C4 52 3 -- -7147 Contractor: Phone#: Fax#: Contact: Phone#: M4--�LA-3c> U50S t `VT Fax #: Contractor License#: Cupertino Business License#: Job Description: PVT, ,J M V-75fZ�k-It—�— +'/0 . r4j&�Q Residential R", Commercial ❑ Valuation: * �50D Project Size: Express FF7 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 1 PCSEWER Commercial b iilding P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial C as Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWERMAIN SERVICE CUPEI�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES I 1BSEISMICR Seismic Residential P 1PRSEWER Residential buildin; P 1RPSS sewer/sanitary sew:r 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P ICPWS or 1RPWS 1PPRSEWG Private Sewage Di:.posal System P 1PCESS Cesspool P 1BPWATER Install/alter Water:'ipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets to Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit F-.e Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B OWNER-BUILDER VERIFICATION Ooc` c)(3f 1. (Check one) I or my immediate famil-.7 (parent,spouse or child) will perform A. ✓All the work authorized by this permit B. A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to _7 De perfa=eda 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer(see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erformed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse side). � E La° d Property Owner's Signature: Date: �� � Job Address: 2kC�� "a` Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 7UPEkTINO Building Department � P JOB ADDRESS: (DO � PERMIT # �(� O 0 � OWNER'S NAME: NIA P►'zz zo PHONE # (* 3) 6Z49— —TI+7— GENERAL CONTRACTOR: FAX # I am not using any subcontractoms 1b L:)igUture Date 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 Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile X +� kA 2 q=-q (Yvn�I/Contr'a'cibr Signature Efate