09030210 CITY OF CUPERTINO
BUILDINC.DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
213 61 COLUMBUS AVE JA PLUM BIN PERharTSSSUEDATE
OWNER'S NAME:
gp CONTROL NO.
•+ONE:
BUILDING PERMIT INFO
ARCHIIECr/ENGINEER: BLDG ELECT PLUMB MECH
RE—PIPIT TO COPPER, REPLACE I
ccc c LIC ENSED CONTRACI'OR'S DECLARATION 60" MAIN LINE INSTALIJob Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z 5 with Sccdon 70(10)of Division 3 of due Business and Profcssiens Code, my license is
y in full force and e 2
v�Z Lic.Ji
License Cl Conuador
3 y Date
AR Hf1ECTS ac:E N
C< I understand my plans shall be used as public records
5C6
u.y Licensed Professional
O< OWNER-BUILDER DECLARATION
�> t I hereby affirm that I am exempt from the Contrattors License Law for the
Mo following mason.(Section 7031.5,Business and Professions Code:Any city or county
y a
R! which requires a permit to construct,alter.improve,demolish,or repair any structureo Valuation
prior to its issuance,also requires the applicant for such permit tfile a signed statement S Ft.Floor Area
—Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q'
Yi- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt dt mfrom and the basis for the alleged exemption.Any violation of ppN 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).
❑I,as owner of the property.or my employees with wages as their sok compensation,
will do the work and the structure is not intended or offered for safe(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes 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.).
❑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 u-
cerse 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. B&P C for this reason
❑1 am exempt under Sec
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-insum for Workees Compen-
_.ion,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 IsCompensation Insurance carrier and Poli n mbar am-
.
Q
cy
Cartier. Policy No.:
CER77 CA OF
EMI,
FROM 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,I shall not
employ any person in any manner so as to become subject to the Workcrs'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
(..d►. I hereby affirm that there is a construction lending agency for the performance of
t3!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lendees Address
V 0 1 certify that I have ad this application and state that the above information is
re
correct.1 agree to comply with all city and county ordinances and state laws relating to
O Vbuilding construction.and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
W
„F",t In liabilities,jud cnu,toss and expenses which ma in anyway accrue against said City �7
V Zin con seq e o the granting of this permit Date G
APPLIC U DERSTANDS D WI MPLY WITH ALL NON-POINT Issued by:
SOUR REG A
Re-roof;
at of Appli U MCLOSURE Date Type of Roof
A S DIS
Will the applicant or uture building occupant store or handle hazardous material
as defined by the Cupertino Municipal apter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant orfuture building tccu se equipment or devices which
it hazardous air contaminants as dcftn t e Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes No
Ilia the hazardoateriais requim crus under Chapter 6.95 of the Califor-
nia Heal S tyCode Scc' 25505,25533 25534.1 understand that if the building
does not u dy have a ten5nt.that it is my nsibility to notify the occupant of the Date
requirem w ' t issu of a cc ' ate of Occupancy. _ Signatu-e of Applicant
All roof coverings to be Class'. or better
ner or authorize nt Date
CITY OF CUPERTINO
REPIPE/SEWE,R/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
6 q z 10
APN # Date:
Building Address:
by -Cr
Owner's Name: Phone#:
Contractor: PlIone
Fax#
Contact: Phone#:
Fax#:
Contractor License#:
Cupertino Business License#:
Job Description: /
a v
Residential Commercial ❑
Valuation:
02-
Project Size: Expfess Standard Large 1] Major
Green Building: Please complete relevant portio:i of the Green Building Checklist& attach it to the
application or if applicable, include in plan set & the sheet index. 57
Green BuildingPoints: v
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
1 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
s.. "` REPIPE/SEWER/MAIN SERVICE
CUPEIkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
( Fee TYPES
I 1BSEISMICR Seismic Residential P
1PRSEWER Residential buildi:lg P 1RPSS
sewer/sanitary sever
q 1PRREPIPE Residential re-pips per fixture P IRPRP
l 1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Wates•Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Fiping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan C1eck P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
-t
�:. Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
',.UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
( C ki UG oe?D-7a'2-!e9
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: ZZE &ML4 FAX #
I am not using any subcontractors:
e Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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
tra afore Date