09040108 77777
CITY OF CUPERTINO iT n A
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
1198 RUPPELL PL WEST COAST PLgMBING. 09040108
PERMIT ISSUE DATE
OWNER'S NAME:
M conn CAFA
SX HA90(399 CONTROL NO.
zNE:
(4 08) 93-7868
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
u p O LICENSED CONTRACTOR'S DECLARATION Job Description
m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Ztu with Section70W)ofDivision3oftheBusinessandProfessionC0 ,andmylicenseis 63 ' -3/L " FM MTR TO STOVE IN KITCHN& INSTL 3/4"
a y in full force and eft�t_7 6 6 33—
t2 Z License Class Ile• GAS
p Date N a�—Contractor -
�] ARCHITECTS DECLARATION LINE FOR DRYR & STOVE
1 understand my plans shall be used as public records
D96
U
4 O y Licensed Professional
w 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Profession Code:Any city or county
K Pi which requires a permit to construct.alter.improve,demolish,or repair any structure
n Z a prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
E s C that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9 $q.Ft.Floor Area
Y F 11 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $800
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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($5W)• 3623004:4 . 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 Profession 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.).
0 I,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 themon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B dt P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 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.
12!have and will maintain Worker's Compensation Insurance,as required by Section
700 of the Labor Code.for the performance of the work for which this permit is issued.
My Workers Compensate Insures carrier and Policy number are:
Carrier.S f f ey h- Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars($100)
orlcss.)
I cenifv 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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
[~-t 1 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.)
a Q Lenders Name
Lenders Address
;)0 I certify that I have read this application and state that the above information is
LL H correct I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (W ree to save,indemnify and keep harmless the City of Cupertino against
liabili' ,jud menta,costs and expenses which may in any way accrue against said City
U Z in nsequcn a of the granting of this it Date
►� PLICA UNDERSTANDS AN IL COMPLY WITH ALL NON-POINT Issued b.1:
S RCE GULATION . V r G(
Re-roofs --
Signatu�cd
p can ontractor Dale
GUs TERIALS DISCLOSURE Type of Zoof
l tite apple t or future bu'ding occupant store or handle hazardous material
as deft by the Cupertino Municip I 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.
0 Yes )No
� 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
,..nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new 1 naterials for inspection.
District?
0 Yes Noo
have read the hazardous materials requirements under Chapter 6.95 of the Califor-
Hca &Safety Code,Section , 533 and 25534.1 understand that if the building
�mcqui
ocs n t currently have a tenant t it i my responsibility to notify ft occupant of the
tits which must or trance of a Certificate of�c a`y. Signatur:of Applicant Date
J1\ r All roof coverings to be Class'n"or better
Ow er or auth 'zed agent Dare
U0�
CITY OF CUPERTINO
REPIPE/SEWS R/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
Date:
Building Address:
[Z -� R6 L
Owner's Name: Phone#:
V`1 vkS& A /
Contractor: Phone#:
11 G 4..5 v� i Fax #:
Contact: / Phone#: GG
CD-o C SC ( — G('7 Fax #: (4,q)
Contractor License#: 7�-6 33
Cupertino Business License#:
Job Description: - ( 3 _ ���' �.-� VkA le 7'E V- '
y _
Residential Commercial ❑
Valuation:
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 sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
+k 1PGASCOM 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 C UPERTINO
REPIPE/SEWERWWN SERVICE
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standard Commission B ALL PERMIT
Fee TYPES
J 1BSEISMICR Seismic Residenti�J P
1 PRSEWER Residential buildir.g P 1RPSS
sewer/sanitary sem er
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1 1 PGASRES Residential Gas P:ping System P
J 1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 1PPERMITFEE Plumbing Permit:?ee Issuance P
1PLMBLNCK Plumbing Plan Cr.eck P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B