09040006 CITY OF CUPERTINO
BUIL DING DIVISION PERMIT � � � ''
PERMIT NO.
BUILDING ADDRESS:
10140 HILLCREST RD ABLE SEPTIC
PERMTT ISSUE DATE
OWNER'S NAME:
DFNNT`' HARS A CONTROL NO.
INE:
(408) 37'7-9990
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
a O O LICENSED CONTRACTOR'S DECLARATION Job Description
ut F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z S with Section 7000)of Division 3 of the Business and Professions Code,and my license is SEPTIC .�BTMENT & NEW SEWER
y in full force and effecy '171 t"
? License Class C^ Contractor
3[—o Date
ARCH rSDECLARATION
C` I understand my plans shall be used as public records
X96
Z. in Licensed Professional
OWNER-BUILDER DECLARATION
,'�<2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
C
K m which requires a permit to construc4 alter,improve,demolish,or repair any structure
rn prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 q
x=0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $8754
.0 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 five hundred dollars(5500). 32616003 . 00
0 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 oroffered for sale(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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li- ..r
cense Law does not apply to an owner of property who builds or improves thereon,and. F x t
who contracts for such projects with a contractor(s)licensed pursuant to the Contractoes
License law. n .,
0 1 am exempt under Sec B&P C for this reason L „!
Owner Date �+1'1 u W
ILJ
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-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 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 t44"-INK
rrsaubn Insurance carpCr*nd Policy number 5/_�(
Cartier. t4 °"L icyNo.: w �`�`'t'flJ t2 1v
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,1 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 0 CONSTRUCTION LENDING AGENCY
I hereby affirm that Utero is a construction lending agency for the performance of
CYi the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
04z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL correct.I agree to comply with all city and county ordinances and state laws relating to
O V building consuuction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City
U Zin consequence of the g ting of this permit. Date
AP U E A D WILL COMPLY WITH ALL NON-POINT Issued b`r:
SUC S.
Re-roofs -
Signature of Applicant/C r Dale
Type of Goof
HAZARD ATERIALS DISCLOSURE YP
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)? �o. All roof: shall be inspected prior to any roofing material being installed.
0Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new I naterials for inspection.
,strict?
D Yes �'Nu
I have read the haz nus materials requirements under Chapter 6.95 of the Califor-
I,Sth& afctyCode, ti SU 25533and25534.1understandthatifthebuilding
vc4 ti responsibility m notify the occupant of the Date
t r issuanccofaCcnificatco!_Pccapany- Signatur,ofApplicant
o
All roof coverings to be Class'n"or better
Owner or authorized agent Date
CITY OF CUPERTINO
REPIPE/SEWER./MAIN SERVICE
CUPEI�TFINO PERMIT APPLICATION FORM
APN#3;,-( Date: 1
U
Building Addrlodo 11&cyer.�
O 's Name: Phone
.s c✓1
Ctractor: Phone#
Fax#: 2--i w,
Contact: Phone#t �4RIv-4 0
Fax#: Aob 2-%ae76
Contractor License
Cupertino Business License#:
Job Description:
Residential Commercial ❑
Valuation:
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion A 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 Deseripti,3n Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary se wer
1 BPREPIPE 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
Z000/T000 Q� ££££ LLL 806 XVA 56:80 6002/TO/60