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09040029 7777777777777777 CITY OF CUPERTINO BUILDING,DIV1S10N PERMIT � � ' PERMIT No. BUILDING ADDRESS: 18890 PENDERGAST AVE CUPERTINO PLUMBING PERMIT ISSUE DATE OWNER'S NAME: r ART Lir' M-TAFFFFR QA$ A 2909 CONTROL NO. SNE: (408) 25: -0618 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH u p O LICENSED CONTRACTOR'S DECLARATION Job Description m I hereby affirm that I am licensed under provisions of Chapter 9(commencing U withScction7000)ofDivision3ofthcBusincssandProfcssionsCodc,andmylicenseis RPLC BR SWR LINE, ROOT BLCKAGE&DAMG �H in full fora and effect n? License Class Contractor y Date ARCHITECTS DECLARATION a< I understand my plans shall be used as public records DyU u.yLicensed Professional 0< OWNER-BUILDER DECLARATION <2 1 hereby affirm that I am exempt from the Contractofs License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county 9 which requires a permit to construct alter,improve,demolish,or repair any structure a-} prior o its issuartcc,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ��] yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $250 0 y .. 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(s5W). 37533043 . 01 0 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 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 , " Y sale.). 0 1,as owner of the property,am exclusively contracting with licensed contractors to IjAN 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 ITAR who contracts for such projects with a contractor(s)licensed pursuant to the contractor's License Law- 0 1 am exempt under Ice. B&P C For s reason Owner Date -' KER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Workces Compen- -don,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 tie performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.D-1-00 7rM Applicant NOTICE TO APPLI :If,after making this Certificate of Exc do ,you ouId become subject to the Workces Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) W A Lcndees Name z Lender's Address U C) I certify that I have read this application and state that the above information is LL Fcorrect I agree to comply with all city and county ordinances and state laws relating to U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against Hto liabilities,judgments,costs and expenses which may in any way accrue against said City G U Z in consequence of the granting of this permit. Date ►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCEREGULA sate Re-roofs Signature of App ✓Contractor T$aoT Of Roof 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. ❑Yes ONo Will a roof s installed without first obtaining an inspection, agree to remove ll the applicant or future building occupant use equipment or devices which it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. .strict? 0Yes C]No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&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 notif�zf,7�4 e requirements whi et prior o issuance of a Certificate of Signature of Applieant Date rr " All roof coverings to be Class ,�. or better Owner or authorized agent Date — CITY OF CUPERTINO U REPIPE/SEWEl2/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # Date:275 Buildin Addres .Qt,d17 Iq A.rf V� Owner's e: Phone#: Contractor t ,p Phone#: ✓�Ba,s' 1 �''�4 t' covin 61 h c, Fax#: Contact: Phone#: L` Fax#: Contractor License#: Cupertino Business License#: Job Description: pp 9P'P/0'u' / Residential Commercial ❑ Valuation: a� ti �Zs 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 rem pipe per fixture P 1CPRP 1PGASC6M 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 CITY OF CUPERTINO -am " REPIPE/SEWER/MAIN SERVICE CUPEF�TINO FEE SCIH:EDULE Quantity Fee ID Fee Description Fee Permit Type Group y 1BCBSC Cal Bldg Standards Commission B ALL PERMIT / Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building; P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 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 Fee Issuance P / 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B Community Development W;. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ''UPEkTiNO Buildi:n De artment JO ADDRESS• PERMIT # O (� `L � 0 Q�,dQf� 2, -C OWNER'S NAME: S, PHONE # GENERAL CONTRACTOR: FAX# I am not using any subcontractors: / ,nature to Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSII*,[ESS 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