03090104 r CI'['Y OF CUPER7'INO
BUILDING DIVISION PERMIT CONTRACI'OR`INFORMATION._;,
�. .. a •5 , I �,,: :
BUaolNc ADDRESS: CUPERTINO PLUMBING PERMIT N'03090104
455 GIQP71F6W A.17
OWNER'SNAME: 10297 S DE ANZA BLV n1wa ISSUE DATE
NE: (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+oo
� LICENSEDCONTRACTORS DECON
iF 1NalIamfnsed Under Provisions
OfChapter
9(commencing lob Description
wtttion7K )ofIDvisianJrf thelicensedBusineo and ProfessnnsCook.and my license
is
<n in full fo¢c ane cffcn.
Liccnea clas _ Lic.a S REPIPE/WATER SERVICE/WATEI �LS®
D
ro ale Cunlrmmr
ARCHITECTS DECLAR TION
fwd lundcrxund my plans shall M dead az public retards rsOOry
yap t; Licensed Pmfcasi...I DEC L .J
g OWNER-BUILDER DECLARATION
<y 1 herebyso affirm that 1 ore exempt from the Contractor's License Law for Ibe '�I{.V'IY�
O o following arson.(Section 703 1.5.Business and Professions Code:,oAny cit.......ly
<m m, which requires a permit to dines the ahem improve,h Permit
ermdemoltt are pair any xbucore
'!ir thattesiuhssmncealso man,to as lbevision of the soon Peuar'S Rleasigned w(Chastatement
vita NathcisiiccnsedPursvanttolhcProvisiormnfNcCommnur'sLimnulaw(Ch.P¢r9 Sq. Ft. Floor Area Valuation
f_ (com meriting with Section 7M)of Division 3 of the Business and Professions Code)or
Q
that he is exempt Ihenefrom and the basis for the alleged exemption Any violation of 36911032 . 00
Section 703 1.5 by any applicam for a permit subjects the applicant to a civil Penalty of
not mere Nan five hundred dollars($500). - -- APN Number .- _ Occupancy Type- __
Q 1,a owner of the property,or my employees with wages as their sole compensation.
will do the work.and the sduaum is not intended or offered for sale(Sec.904,4,Busims _ tttf
ro Profession
bui dorimprovesa Comunthereor.n.License Law dm not apply to an owner of 202 — UNDERFLOOR PLPJMBQI�VG
p pemplosuch imon.andwhodoessuchwnrk himulredor lhrsele It.
howownever.the
or impounmemproold within
ne em of
orortercd for sale.v, 301 — ROUGH PLUMBING
M1owevcr.Ne building or improrcment is sold within one year o!cnmplction.Ce ownery
builder will have the burden of proving that he did not wild or improve for purpose or 302 — TUB & OR SHOWER
sale
.). 502 — FINAL PLUMBING ENERGY
co 1,as owner of Project
property,,B exclusively ctmrufins with licensed contractors m
comma des not (Sec.0 in.Business and Professions ds or
po Conoamon.Li- 506 — GAS TEST
come Law docs not apply loan owner of property who wilds or hmpmvo Contra,and 507 — FINAL PLUMBING
who for such projects with nN
withacomor(s)licensed pursuant e Convectors
License
Law.
Law.
ta
Q lam accept under Scc. ,Bh PC for this rtazon
Owner Date
Adikk WORKER'S COMPENSATION DECLARATION
I hereby a(nrm under penalty of perjury one of Ce following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker scamper.
saurian,as provided for by Section 37110 of the hwr Code,for Ne perfomoree of Ne
w k for which Cen
is Penn it is issued.
have and will maintain Worker's Compensation Insurance,as required by Seclon
3700 of NC Libor Code,for the performance of the work for which this permit is issued.
My Worker Com`rc nsaoon u nao/p her and Policy number am:
Cartier T e /Bol POlicy Na.:7L�I Un/JZ O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less.)(Tots section head not weompleted iffire,parmim is for one hundred dollars I$]had)
I cenify Nal in da performance of the work for which this permit is issued,I shall not
employ any person in any manner so as In become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,aBcr making this CeniBcate of Exemption,you should
become subject to the Worker's Compensation provisions of Nc ISMm Coale you must
D O forthwith comply with such provisions Or this permit shall w deemed mvnked.
z'N CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the Performance of
Z thc work for which this permit is issued(Sec.3(197.Civ.C.)
:J ELender's Name
3' Lender's Address
D
J Q 1 moify that I have read this application and state that me above information is
y F^ comet.l agree to comply with all city and county ordinances and some laws missing or
7 V building construction.and hereby authorise representatives Of this city to enter upon Ne
4q .hove-mentiuncd property for iapeaion purposes.
gy (We)agree to save,indemnify and keep harmlesss Be City of Cupertino against
h Iiaccoaeancrace nu,coals and swhicM�mey many' yaccmc against said City
;� z m colucqucncc of the osis isAPPLICA /
~ SOURCE NT LAER S WI C L WITH ALL NON-POINT Issued by: Date
Signal �S G Re-roofs
B p nU nlranor Dam
HAZARDOUS L SURE Type of Roof
ilI the applicant or future buildi g Occupant store or handle h"asooe,matedai
as define by the Cupertino Municipal Code,Chapter 9.12,and tbe Health and Safety
Code Section 25532(.)?
❑resNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fuwrc boldins Occupant use If a roof is installed without first obtaining an inspection,I agree to remove
p equipment Qu or devices which g p
i1 neo? us air contaminants az dclncd by the Bay Area Air Quality Management all new materials for inspection.
isdin? ��/
❑Yes ar�u .
doslI have Sir ¢ria) nu 4.1a damean6.95of Cc Calhfa>
tzl Safi h e ti m2 SJl iftyl crso theoccupso oiling
mq.i yM1 r c a mihilitym nnuly Nc«cuyent of Nc
ntwi tv' re, arc aaaomna"e,.O Signature of Applicant Date
neo redthrnsadagenl v/�/ Dame All roof coverings to be Class "B" or better
CITY OF CUPERTINO
Zen REPIPE/SEWERS/MAIN SERVICECOF
p 3 D
CUPERTINO PERMIT APPLICATION FORM
APN# �/ I ' � 3 a Date:
Building Address:
D 1525�
Owner's Name: ho e#:
l D 5 ,/�04f L
Contractor Phone: (4/0S; License#:
Cv �ir�v z43-27
Contact: ,lone,. Cupertino Business License #:
Building Permit Info: �J
Bldg ❑ Elect ❑ Plumb �T
Job Description:
Residential 7P Commercial ❑
Cost of Project,.' W
M
Fee ID Fee Descri tion Fee Group
PPERMITFEE PlumbingPermit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BU LIC Business License BU LDING
Z� 3 . 2-