09030072 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � � � � �
BUILDING ADDRESS: PERMIT NO.
81
OWNER'S NAME: PLUMBING PER MISSUEDATE
,O 1725 eGER9 AVE STE (2 SA CONTROL NO.
ARCHI'fECIYENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
COPPET_ RE-PIPE FROM WATER D D O D
u c c LICENSED CONTRACTOR'S DECLARATION METER THRU OUT HOUSE Job Description
m C I hereby affirm iuns rm that I am licensed under provisions of Chapter 9(commencinis g
-Z m with Section 7000)of Division 3 of the Business and ofessCode, d license
H in full force and effect CS L�g (0 .,
? License ass �l aJ
y Date — n Contractor
ARCHITECTS DECLARATION
a< I understand my plans shall he used as public records
D U
4 L6 y Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
t m which requires a permit to construct,alter,improve,demolish,or repair any structure
n rn prior to its issuance,also requires the applicant for such permit to file a signed statement
zC that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
X h (commencing with Scction 7000)of Division 3 of the Business and Professions Code)or
Axethat he is exempt therefrom and the basis for the alleged emption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(5500).
❑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 q 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.).
❑I,as owner of the property,am exclusively conuacting 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 pmjects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this mason
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-
-otion,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 Workers C pensation lasuran carrier and Policybe :�/�O
Carrier. U Policy No.� �'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
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 Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subject to the Workces Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed mvoked.
Z CONSTRUCTION LENDING AGENCY
E.r rY3 I hereby affirm that there is a convection lending agency for the performance of -
a+> the work for which this permit is issued(Sec.3097,Civ.C.)
W�1 r Q Lender's Name
z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
4.r" cored construction,
agree to comply with all city and county ordinances and state laws misting to
O V building consction,and hereby authorize representatives of this city to enter upon the
;4 above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
IA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMP FALL NON-POINT Issued b3: Date
SOUWUEGUL IONS.
Re-roofs
si Applicantse r Dale Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
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 roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant future building occupant use equipment or devices which
If a roof;s installed without first obtaining an inspection,I agree to remove
it hazardous air co mmans as defined by the Bay Area Air Quality Management all new r.laterials for inspection.
strict?
❑YesNu
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Heal th&Safety Code,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 which must be met pn to i ancc C 'nate of Occupancy. y Signature of Applicant Date
o
or authorized agent
Date. All roof coverings to be Class'V'or better
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEi�TINO PERMIT APPLICATION FORM
APN # 35*& 6 e0 `0� Date: 3 —1,,'-"2- r
Building Address: eE'-�A-� 0
wne 's N e: w Phone : ��
c
ontra tor: ae=YM4
1�11�14 hone : y0 3
-A 11-1r1g1j4 ` � q
L Fax#: p
Contact: J Se 1.Zj Z Phone#:
Fax #:
Contractor License#: eYsca
Cupertino Business License#:
Job Description:
Residential Commercial ❑
Valuation:
Projec Size: Express D Stand -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 re-pipe per fixture P 1CPRP
1PGASCOM 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
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`MkTINO
Building Department
JOB ADDRESS: PERMIT #
s ko OQO3�o`72
OWNER'S NAME: h (- PHONE #4yp 0 a
GENERAL CONTRA TOR: , �„� qoe!�rSLZIRT
r
I am not using any subcontractors:
5 ignature Date
Please check applicable subco actors 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