09060057 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �' T'R t.) I�� M�T��N:*
BUILDING ADDRESS: PERMIT NO.
4 RAINBOW DR PACIFI
OWNER'S NAME: PERMIT ISSUE DATE
S A CONTROL NO.
408) 452-8633
ABUILDING PERMIT INFO
RCHITECI7ENGINEER:
BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACTOR'S DECLARATION Job Description
m C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
:D�y in full force and effecL EXTSN CF SEWR LATERAL ,
? License Gass Lie.M
t-p DamContractor
e < ARCHITEcrS DECLARATION
E I understand my plans shall be used as public records
�a.
y o y Licensed Professional
y� OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
08 following reason.(Section 7031.5,Business and Professions Code:Any city or county
e${ which requires a permit to construct.alter,improve,demolish,or repair any structure
Zprior to its issuance,also requires the applicant for such permit to rile a signed statement
=c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.
1, $ (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(5500)_ 36611044 . 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 ns Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
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
sal.).
❑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 Li- ARY
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.
❑1 am exempt under ec. B&P CP C for I / �,�v AN T
Owner ' am %
AVORAM'S COMPENSATION DE CRATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
.don,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued
❑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 Workers ompen Gon I unnce carrier and Polity number arc: / /��
Carrier Policy No.:__S/L�7T'
GeRTIWATE 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 to omc subj t to Workers'Compensation
Laws of California Da
Applicant s v�
NOTICE TO APP .1 after Ofileffing 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 0 4 CONSTRUCTION LENDING AGENCY
[~i►�-+ I hereby affirm that there is a construction lending agency for the performance of
(x.7 the work for which this permit is issued(Sec.3097,Civ.C.)
ALender's Name
Z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-t rn 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 G^Y�
t"'t APPLICANT UNDER ST NDS AND WILL C MPLY WITH ALL NON-POINT Issued by:
Dam
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 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 ❑No
Will the applicant or future building occupant use equipment or devices which
If a roof i s installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.urict?
❑Yes ❑Nu
I have mad the hamnkxrs materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,Sections 25505,25533 and 25534.1 understand that if the building
does
autficrivig6dDam
01/22/2008 09:50 .FAH 408 777 3333 CITY CUPERTINO [MOO 1/002
CITY OF CUPERTINO
REPIPE/SEWERMAIN SERVICE
CUPEkTiNO PERMIT APPLdICATION FORM
APN# 3 r (-P j j v bate: _ I
Building Address:
Owner's Name: Phone#:
�
JKlel(.. "A1owc, S t, V(Ct NC . Fax#: 40t -q(X2—
Contact:
vContact: Phone#: jp%- ( cLfo- 2,V--D
-D,zI2 AT ( Fax#A NA ( Qv
Contractor License#: g4-Sq�'(P
Cupertino Business License#: 2 Z p
Job Description:
a S i of l 6+ SPt�r�� Gt,LQ,"t
Residential Commercial
Valuation:
Green Building Check list must be completed and attached to this application.
Green Building Points:
Quantity Fee ID Fee Descriptbn Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1 CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEXSMICOM Seismic Coinmeicial P
/ 1BSEISMICR Seismic Residential P
/ 1PRSEWER Residential building P 1RPSS
sewer/sanitM sewer
CITY OF C'UPERTINO
REPIPE/SEWER/I AIN SERVICE
OF
.UPERTINO FEE SC HEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential buildi.ig P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pip:,per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas P.ping System P
1-4 Outlets
1 BPGAS Gas Piping System 5+ Outlets P
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
Community Development
10300 Torre Avenue
a'_ Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
"UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
' �-j -�YN�()L , 7:>r (5 o (ooc� ��
OWNER'S NAME:
#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and com Clete 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