09060167 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
ITR� +QR IM�TIf�N.:
PERMIT NO.
BUILDING ADDRESS:
10750 RAE LN DAHL PLUMBING
PERMIT ISSUE DATE
(650) 32'--5500
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Zu, with Section 7000)of Division 3 of the Business and Professions Code,and my license is GAS PIPIT CUT & TEST; RE-DIRECT SMALL SECTION
n Z y in full force and effe /� -2 OG CIO19
Gs AS
Z License Class___L—
y p Date &g Contractor
RCHrMCT'S DECL.ARA ON
al understand my plans shall be used as public records
�6U
a H Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following mason.(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
n�W prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
7;!; that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q
YX S (commencing with Section 7000)of Division 3 of the Business and Professions Code)or S1500
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500). 35607075 . 00
❑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 or offered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law dors 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U-
censc Caw 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.
❑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-
,ation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Workees Compensation Insurance carrier and Policy number are:: ��-�
Carrier.4/'I/V 9Z'k 14 Policy No.:�f gn—IJ�-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit is issued,1 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 Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
z 2 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 Q Lender's Name
=Z L.endees Address
[certify that I have read this application and state that the above information is
V" correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building convection,and hemby 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
E-4 to liabilities,judgments,costs and expenses which may in any way accrue against said City /y
U Z in consequence of the granting of this permit. Date 30
P- APPLICANT
Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
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 ma - being installed.
❑Yes If a roof s installed without first obtaining an inspection, ag e
Will 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? 94w_❑Yes
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
Zclf— All roof coverings to be Class'A"'or better
Owner or authorized agent Date
o9 0(P cs 1
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 5-G 0 -7 0-7 (P - v J Date: �_ :�O —o
Building Address:/`0' 7S_0
0 7 D P-a-e-
Owner's Name:
: 3X-1 _Cl� 00
/�a�//�i Ci► ✓ Fax#: (0 a v t 3 8 3 g y
Contractor License#: D p
Cupertino Business License 251 t�_
Job Description:
Residential Commercial ❑
Valuation:/,_�OO dr'�
Project Size: Express LJ 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 Descripi:ion Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1 BCBSC Cal Bldg Stant ards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Descript ion Fee Permit Type
Group
1BCBSC Cal Bldg Stand�xds Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential buil ling P 1RPSS
sewer/sanitarys ewer
1PRREPIPE Residential re-pipe per fixture P 1RPRP
IBPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Waler Pipe P
1BPFIXTURE Plumbing Fixtu•e P
1 PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Perm:t Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Docur:ientation Fee B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
„ ` ` Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
%PEkTINO
Building Department
JOB ADDRESS: PERMIT #
-ZS-0
OWNER'S NAME: C==g PHONE # — -2-j— g-ZaQ
GENERAL CONTRACTOR:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS 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
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