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09040125 CITY OF CUPERTINO � � � BUILDING DIVISION PERMIT10 PERMIT NO. BUILDING ADDRESS: n0nj 01 10271 IMPERI CUPERTI] P pERMTrISSUE DATE OWNER'S NAME: SA CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH COPPER REPIPE 9 o c LICENSED CONTRACTOR'S DECLARATION Job Description U1 hereby affirm that I am licensed under provisions of Chapter 9(commencing z U3 with Section 7000)of Division 3 of the Business and Professions Code,and my license is o y in full force and cfTL 2 L Lic• Z Q Q v�z License�Ia�s C ✓ # y Dam_�— Contractor e ARCHITECTS DECLARATIO ez 1 understand my plans shall be used as public records ?aV G l-Licensed Prufcssional OWNER-BUILDER DECLARATION e1 I hereby affirm that 1 am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county 4.9 which requires a permit to construct,alter.improve,demolish,or repair any structure y rn prior to its issuance,also requires the applicant for such permit to tilt a signed statement Ft.Floor Area Valuation z< that he is licensed pursuant to the provisions of the Contractor's Uccnse Law(Chapter 9 q Fy G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i 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). 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 forsale(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 We.if, however,the building or improvement is sold within one year or completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 0 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Prowha builds de improves tractors Li- candense Law does not apply to an owner of property P who contracts for such projects with a contractor(s)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 I hereby affirm under penalty of perjury one of the following declarations: LI 1 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. C!rI have and will maintain Workers 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 arc: Carrier. �T z.+C Policy No.: 7 i 3'vv3 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 or 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 or 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. ►-+ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of a the work for which this permit is issued(Sec.3097,Civ.C.) W A Lendces Name ]Z Lender's Address U C) I certify that I have read this application and state that the above information is torted.I agree to comply with all city and county ordinances and state laws relating to V building construction,and hereby authorize representatives of this city to enter upon the 147 L>a above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses •It may in any way accrue against said City rA U Z in consequence or o mit Date ►- A p DER S N COMPLY WiTH ALL NON-POINT Issued by: S RCEREGU V Re-roofs Sig nrA ucarmucontractor Dam 'r of F:oof HAZARDOUS MATERIALS DISCLOSURE Type 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. 0Yer No If a roof .s installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which At hazardous air contaminants as defmncd by the Bay Area Air Quality Management all new materials for inspection. District? ( n Yes 014- I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Co ons 5()5.25 33 and 25534.I understand that if the building does not cu Ave a ten a' my bility m notify the occupant of the Date re u' ns which must tell rte iss tic of Ocgl ncy©� Signaturf:of Applicant All roof coverings to be Class" "or better Dam Owner or a d agent fi�c siCITY OF CXPERTINO REPIPE/SEWEIUMAIN SERVICE CUPEt�TINO PERMIT APPLICATION FORM APN # �� ( ( U Date: 2_0(7 Building Address: -2 y Owner's Name: Phone#: 2 cj-2- Contractor: Phone#: Z UG < v C�- Fax#: Contact: + Phone#: -3v 9 _ 3 1/// Fax #: Contractor License#: G c{ 5 v� Cupertino Business License#: Job Description: ��-- Residential Commercial ❑ Valuation: F v 7� Project Size: Express Standard 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 ;ewer 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 TYPES Fee 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/NIAIN SERVICE CUP TYOF O FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residentia: P 1PRSEWER Residential building P 1RPSS e2sewer/sanitary sews-r IP PIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Di:;posal System P 1 PCES S Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Pi:)ing System P 1-4 Outlets 1BPGAS Gas Piping System: 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Ch l-ck P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B