09050066 777777777777
.777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT INF
PERMIT NO.
BUILDING ADDRESS:
10575 OR. INGE TREE LN ALL VALLEY PLUMBING 09050066-
PERMIT ISSUE DATE
OWNER'S NAME:
AhU?9 9 9 CONTROL NO.
PHONE:
(510) 37E -4816
BUILDING PERMIT INFO
"HITECC/BNGINEER: BLDG ELECTPLUMB MECH
0 0 a 0
',o c LICENSED CONTRACTOR'S DECLARATION Job Description
v 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 WATR H EI,TR R P LC MNT
"C H in full force and eff
Z License Class
Date _co 7 Contractor
o
ARCHITECTS DECLARATION
�+y I understand my plans shall be used as public records
�qU
5
0:5 y Licensed
Professional
OWNER-BUILDER DECLARATION
` 1 hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
y'y prior to its issuance,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 �q
Yt= (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $350
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). 31634009 . 00
❑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 Contractors 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 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 Contractors li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury One Of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
eation,as provided for by Section 3700 of the Labor Code,for the performance of the
rk for which this permit is issued.
I 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 Work/eerg Compensation Insurance carrier and Policy number ares:: 7�
ier (J( t Policy No.:
Gtr
CERTIFICA OF EX MPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis 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 Workcrs'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 Codc,you must
Z, 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
Q! the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
]Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
(L H correct 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
Uabove-mentioned property for inspection purposes.
>4 Wa (We)agree to saw,indemnify and keep harmless the City of Cupertino against
� s
04 liabilities,judgments,costs and expenses which may in any way accrue against said City J t yy
V In in consequence of the granting of this permit. Date /
.� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
SOUR GU ATIONS.
.S 4s ,p Re-roofs
Signature of Applicant/Contractor Date Type Of 1�OOf
HAZARDOUS MATERIALS DISCLOSURE
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 4;we 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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
❑Yes @ 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
docs not currently have a tenant,that it is my responsibility to notify Ute occupant of the
requirements wh' m t be met ' r w i ante of a Certificate of Occupancy. Signature of Appl icant Date
�09 All roof coverings to be Class' or better
Date
Owner or authorized agent
ooL
CITY OF CUPERTINO
Lac, WATER BEATER
CUPFS ANO _ PERMIT APPLIC-ATION FORM
Date:
rAPN �Address:
1p� ®ran rem L- anC
Phone #:
Owner's Name:
Phone #:
Contractor:
Fax #: jl _ (OLt �% 7c
Contractor State License #:
Cupertino Business License #:
Phone #:5,7C
Contact:
r-"i �jeti r C l t2r"i r, I< Fax #: �f C-1
C
Cer 7f'
t
uilding Permit Info:
Bld Q-- Elect [�]---
P dumb P- Mech
ResidentialCommercial ❑
Job Description:
12
ed F] On Platform ❑ Bonded ❑ New Location ❑ Replacement
Stra
PP
Valuation (cost of project):
cJ U
Project Size: Express ❑ Standard ❑ barge ❑ Major ❑
Green Building: Please complete relevant porl:ion of the Green Buildin Checklist attach it to
the application or if applicabl include in plan set & the sheet index.
;reen Building Points achieved:
Revised 6/16/08