09040136 CITY OF CUPERTINO w
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BUILDING DIVISION PERMIT (3RA �T
BUILDING ADDRESS: PERMIT NO.
1
PERMIT ISSUE DATE
OWNER'S NAME:
A: RUBS 2�tje5 is A 6.2069 CONTROL NO.
408) ;;88-6607
BUILDING PERMIT INFO
ARCHrrEC17ENGINEER: BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACTOR'S DECLARATION Job D2SCnptlOn
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
� y in fullforeeandeffecL (o�y� REPAIR BROKN SEWR LINE_
Z License Clads Lle•
nFDam �t 2 o Contractor u skirt Gots, t
e A CHTIECTS DECLARATION
z a I understand my plans shall be used as public records
Jul U
O in Licensed Professional
n
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
C p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
1 which requires a pcmuit to construct alter,improve,demolish,or repair any structure
y'n prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
Ft.Floor Area
2=0
that he is licensed pursuant ro the provisions of the Contractor's license Law(Chapter 9 Sq
y t–$ (commencing with Section 7000)of Division 3 of tirc Business and Professions Code)or
.0 .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
— 81000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 316 3 31: 2 . 00
❑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 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 contractors)licensed pursuant to the contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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-
sation,as provided for by Section 3700 of the Labor Code•for the performance of the
work for which this perrnft 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 Compensation Insurance carrier and Policy number ate:
Cartier.Re P%A��I t_ 'k fvQ Policy No.:b1:13`-r \\�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(chis section need not be completed if the permit is for one hundred dollars($1110)
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 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z R CONSTRUCTION LENDING AGENCY
Fr 1 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 A Lenders Name
aZ Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
(L 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
above-mentioned property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of %spermit. Date
APPLICANT ND WILL COMPLY WITH ALL NON-POINT Issued l:y:SOURCE R ULAz-1' Re-roof iSignature of ApplicaDare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defincd 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 o
If a coo is installed without first obtaining an inspection,I agree to remove
Will the applicant or utum building occupant use equipment or devices which
tit hazardous air contaminants as defincd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Lj�Nu
1 have read the hazardoL materials mquiremcnts under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not current t,�ILIS msponsibility to notify the occupant of thereyuiremcn ich m t snUfcaic of�cuPancy. Signatu-e of Applicant Date
A' All roof coverings to be Class';."or better
Owner or d agent Date
CITY OF CUPERTINO
()g 04
'&- REPIPE/SEWI;R/MAIN SERVICE
CUPEi�T1NO PERMIT APPLICATION FORM
APN # Date:
Building Address:
toy
Owner's Name: Phone#: G�G� _ lG�o�
L
Contractor: Phone#: 4ko- 34 o O
Fax#:
Contact: Phone
r1 fL`�AS Fax#:
Contractor License#: v5 jv
Cupertino Business License#:
Job Description:
� L V7f
Residential Commercial ❑
Valuation:
X000
Project Size: Express Standard Large ❑ Major LJ
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set.6; the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 11CPSS
sewer/sanitary sewer
1BPREPIPE Commercial r(;-pipe per fixture P 1CPRP
1PGASCOM Commercial Cas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Stan iards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
o
REPIPE/SEWEIVMAIN SERVICE
CUPEIZTINO FEE SCHEDULE
Quantity Fee ID Fee Descriptic n Fee Permit Type
Group
/ 1BCBSC Cal Bldg Standards Commission B ALL PERMIT
/ Fee TYPES
I 1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sever
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixturf; P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
r 1TRAVDOC Travel & Documentation Fee B
1 1BUSLIC Business License B
Community Development
r " 10300 Torre Avenue
a a, Cupertino CA 95014
: ;: ..
Telephone(408)777-3228
^CITY OF:
Fax(408)777-3333
;UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT # t0 0 r ( 0
OWNER'S NAME: Q PHONE # �(c� 3qos3
GENERAL CONTRACTOR: FAX# -_;A
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and com Clete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
7777FIooring-, 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