09040057 CITY OF CUPERTINO ;
BUILDING DIVISION PERMIT � � � .
PERMIT NO.
BUILDING ADDRESS:
21845 HERMOSA AVE BT PLUM]3ING IN
OWNER'S NAME: N k t1J r 0V_)o( J 6,y W-y L°I_ PERMTT ISSUE DATE
NT_ Thr VF
.Ii VT7 CNfIIA] F�J I ►1 S A CONTROL NO.
ONE:
(408) 3L6-9149
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 � 0
u O OO LICENSED CONTRACTOR'S DECLARATION Job Description
U 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 MAIN WATER PIPE FM ST TO HSE I S, FIX WTR MAIN
y in full force and effect.
v�z License CI Contractor
M Date_
A CHrMCrS DELLAAW�
1 understand my plans shall be used as public records
�yU
`a f- Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
"y prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 (1
YF+ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3000
a R E 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 fire hundred dollars(M). 357 16 130 . 00
❑1,u 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 ask(Sec.70".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 am 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 Law.
❑1 am exempt under Sec B&P C for this reason
z5ANITARY
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-
.-tion,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 am:
Carrier. 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 less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any man r Io v LDmc subject to th;W"ofters'Coompensation
Laws o(Califor��,DateApplicant ?terNOTICE TOAPPLICANT:If,afScr maiming this Certificate you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z r-t CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(Y,✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endces Name
aLender's Address
I certify that I have read this application and state that the above information is
LUL correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city ro enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which m m any way accrue against said City
V z inconsequence oC granting of this i Date
APPLICANT UN ERST LL PLY ITH ALI,.NON-POINT Issued b/:
SOURCE Ri& S-
Re-roofs -
Signature Applicant/Contrutor Date
HAZARDOUS MATERIALS DISCLOSURE Type of'loof
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:;shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
it hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand dual if the building
docs not curre ly have a tenant,that it is m hi' to notify the occupant of the Date
requirements h mist be mel ' r uance o c urate of Occupan C Signatur of Applicant
(F a All roof coverings to be Class",or better
Owner zed gent Date
An
CITY OF C-.UPERTINO
REPIPE/SEWEIR/MAIN SERVICE
CUPEt�TINO PERMIT APPLICATION FORM
APN # h Date:
17 1 (P Do , C)0
Building Address: I � H Y V►'�C3 S�,� AJ-R . Cv f k Ytc ►t� 1CA qri
Owner's Name: S `V � �� (�N Phone#: _ 1 _ q �.
Contractor: 'v Phone#:
BT Fax#:
1 �
Phone#:
Contact: /�-
Tt�-0C
Fax#:
Contractor License
k0 -1
Cupertino Business License#:
Job Description: h Xv"', " =I.- , T1 Fu v`• �. v' -�
Residential Commercial ❑
Valuation: 3 V 0 �_
Project Size: Express N
Standard LJ Large LT—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 ICPRP
1PGASCOM Commercial G;is 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/SEWER'MAIN SERVICE
CUPE(�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
j 1BCBSC Cal Bldg Standards Commission B ALL PERMIT
( Fee TYPES
1BSEISMICR Seismic Residentizl P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sew er
1PRREPIPE Residential re-pipe per fixture P 1RPRP
J 1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit lee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gis Insp. P
1TRAVDOC Travel &Documentation Fee B
1BUSLIC Business License B