09060032 77 77777777
CITY OF CUPERTINO `
BUILDING DIVISION PERMIT G�1T ► T+f � r� '
PERMIT NO.
BUILDING ADDRESS:
PERMIT ISSUE DATE
OWNER'S NAME:
ST 203 _SWRAAV.2 0 0 9 CONTROL NO.
PHO
408 259-19
BUILDING PERMIT INFO
.ttCHITECWENGINEER:
BLDG ELECT PLUMB MECH
u o pLICENSED CONTRACTOR'S DECLARATION fob Description
W C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z try with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force and NEW COPPER WATER MN
�Z License Class
;go Date — Contractor
w AR HITECTS DECLARATION
U
I understand my plans shall be used as public records
�a
4 c H Licensed Professional
ret OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
Zp O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<.P 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 role a signed statement
that he is licensed pursuant to ale provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Yrco
F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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($sore.
32613066 . 01
0 I,u 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 docs not apply to an owner of
property who builds ar 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
constroct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 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:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
m,as provided for by Section 3700 of the Labor Code,for the performance of the
.,rk for which this permit is issued.
0 I 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 Compensation Insurance carrier and Policy number � 0
Carrier VA t. 0 ' 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.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.
Z, CONSTRUCTION LENDING AGENCY
Fr rte. I hereby affirm that there is a construction lending agency for the performance of
p� 7
the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
0 z Lcndees Address
U O I certify that I have read this application and state that the above information is
it.►' correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
Gra 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 which may in any way accrue against said City (,
U Z in consequence of the granting of this permit. Date 6* C �/
"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE E ULATIONS.
Re-roofs —�
S*natum of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of F.00f
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Co .Chapter 9.12,and the Health and Safety
Cod.,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Ya o
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
—nit hazardous air contaminants as der y the Bay Area Air Quality Management all new n laterials for inspection.
trio?
0Yes o
I have rears 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 notify the occupant of the
requirements w ' u met prior to uancc o(a Ccrtificatc of Occ panty. Signature of Applicant Date
Owner All roof coverings to be Class'J ``or better
r aur orized agent Dare
�(:)(C) 003
CITY OF 12UPERTINO
I,SM REPIPE/SEWEIR/MAIN SERVICE
CUPEi�TINO PERMIT APPLICATION FORM
APN # Date:
(PC? . v�
Buildinj Address:
1 06
Owner's Name: Ito S y„,'L�4-rL3 Phone#: J .7 j
1/0
Contractor: Phone#:If o`6 26 `3 6 C1
Fax#: I/--<�- 26 ` - t `4 V
Contact: Phone#:
04-6 6)q/0 /t q Fax#:
Contractor License#:
Cupertino Business License#: 0 y
Job Description: j-� , a ti ,
Residential Commercial ❑
Valuation:
Project Size: Express EJ 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
1PGASCOM Commercial G:is Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICOM Seismic Comrr ercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWER/VUIN SERVICE
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standard,, Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residentiz.1 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 Di3posal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Pifing System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Chock P
1PLMBINSP Other Plumbing/gzs Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Or OF Fax(408)777-3333
f'UPERTINO
Building Department
JOB ADDRESS: ja 5o6 PERMIT # �
OWNER'S NAME: PHONE # 14 d'5 L/3 3`i 3
GENERAL CONTRACTM: ,/tie., FAX #
I am not using any subcontractor
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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