04100029 CITY OF CUPERTINOBUILDING DIVISION PERMITCONTRACTORINFORMATION Ads -
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BUILDING ADDRESS: _ ACE PLUMBING PERMIT NO 04100029
1141 HOLLYHEAQ LN
OWNER'S NAME: FERMTI'LgUEDATE
ja 1h HERBERT & PATRICIA
NE: SANITARY N0. CONTROL NO.
(408) 226-2243
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S Javyv IN Al
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mF I hemby affirm Net I am II¢mcd uryks pmviaions of Chapter 9(mmmcnci it F Iy YY{�P�tgp'i\'l l7Bp'�
ix3 with5auon 7IXXpdf Division3of NCB and Pr ofessionsC=mdmylieenw is - - .-
nfo[ o andeffen_a REPIPE (2 BATHRMS)
n Z Licertslass L'e.N
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qqARCHI'IECI-S DECtA i
32 1.
IundcrsunJ my plans shall Wuud as Puhlig or
DEC 2U04
JyU
0.G Licensed Pmfcssional
OWNER-BUILDER DECLARATION BUILDING
I'bemby alum Nal I am exempt from use Conmmors License law for the
O C following mason.(Section 7031.5,Business and Pmre tions Code:Any city or county
2 r which mquiress a permit to construct,she.improve,demolish,or repair any stmcwm
—iy pdoin its issuance,also requires the applicant for such Permit o file a signed statement Valuation
z< Nathcklicensed purwammNcprovisionsoftheContractoriLkxnse aw(Chapter 9 Sq.F[.Floor Area
y~$ (commencing with Steelton 7")of Division 3 of the Business and Pmfcasiow Code)or
y that he is attempt rMrcfrom and one basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant or a civil penalty Of $19x(i Mer0 0 Occupancy Type
not more Nan five hundred dollars(5500).
I,as owner of the property or my employees with wag"as their sale compensation,
will do Ne work.and the structure is our intended oroffemd for sm,(Sce.7W.Business Required Inspections
and Profession Codc:The Convectors Life.Law dao Inst apply to an owrf r of q P
pro,nywho Wildsorimpmws rhermn,and wbodoessuch work himselfor through his
own employees,provided thmsuch improvements are not intended moReeed for sale.IL -
however the building or improvement is sold within one year of comPletion,the Owner'
builder will have the burden of proving that he did nal Wild or improve for purpose of
sale.).
1,as owner of the pmpeny,am exclusively contracting with licensed conmrms 10
consumer tbe proper(Sec.701x.Business and Professions Code:)Tie Cmu m7er's U. -
ecom law does not apply In an owner of property who Wilds or improv"Merton,and
who contracts for such pmjccU with a commemr(s)licensed puesuanuo the Contractors -
LKenaeLtW.
❑I am exempt under Sec. ,B k P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pointy of perjury ane of Ne following dodaratimuc
1 haw and will maintain a Ceruficote of Consent to self-insure for Workers Compen-
tion,as provided for by Section 3700 of the labor Code,for the performance of Inc
wwk for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
37W of Ne Labor Code,for the Performance of the kIm ch this permit is issued.
My�Vorkcr's nmPensation lnwnntt amuend Poli ��[[W�r�a�rt�:��s��
me Policy No.:M 4,9 0<L_.••t�
CERTIFIATEOF EMPI ION PROM WORKERS'
COMPENSATION INSURANCE t
(This auction need not becompleted if the Permit isforme,hundred dollar(SIM)
or less)
1 cenify Not in the Performance of the work for which this permit is issued,I shall not
employ any person in any manner w a m become subject o the Woders'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Emmiumn.you should
become subject On the Worker's Compensation provisions Of the Labor Cade,you most
2 forthwith comply with such proeirs or this permit shall W debmcd nwrked.
zO CONSTRUCTION LENDING AGENCY
'r. 1 hereby M.that chert I,.construction lending agemy for the performance of
C? Ne work for which this Permit u issued(Sec.3097.Cih,C.)
W Q Landers Name
6. Lenders Address
V 2 1 cenify that 1 have read this application and stem that Ne shove infoout miun is
Dn (•" cancer.I agree to comply with all city and county ordinances and sure laws relating to
pU Wildingconstruction,ni toand w.indeyamhadmrePresemaliacso,City of mentorupon the
} aWve.memiuned property for inspection purposes
6 es judgments,
agree to saw,indemnify and keep humins Ne airy of Cup. against
liabilitl",judgmcns.costs andcxpcnses which may in any way creme against rid City Q
U'Z in consequence of the granting of this permit. Da e
�••' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE R ULATIONS
r "" YA-A_�'U��� Re-roofs
Sllntnu of ApPli ✓Conuwmr
Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ted applicant or form building rccupantarom or handle hamodees material
as chimed by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Codc,section 25532(a)? ;•j: All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection,I agree to remove
Will Nc applicant or Tum Wilding Occupant taw .Ail Qu of M.n.iwhich
it havaednm air em=,nan ss JcfincJ by Ne Bay Arta Air Quality Manag<mcm all new materials for inspection.
District?
❑Yes No
I have mad the hassrdous materials requirements under Chapter 6.95 of the Califor.
nice Health It Safety Code,Sautes 25505,25533 tad 25534.1 undcnmnd dot if the Wilding
Jocs wl currently haw a lemm,that it is my responsidi ity be notify IW omuprm or the
require Is whichmuIImmet poor toimumceofggEUillmmofOccu ry Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner to amhodsed apeni V IDo
A-ZiN Community Development
10300 Torre Avenue
J Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #
�il�( of hea. Lel �o 0&
OWNER'S NAME: PHONE # 40- 3 -066-(—
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
^G 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 --1
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/Contractor Signature �o Date
I
CITY OF CUPERTINO Z
REPIPE/SEWERS/MAIN SERVICE
CUPERTFINO PERMIT APPLICATION FORM
APN# / Date:
3 Z
Building Address:
rl �D // ez)d Lawe
Owner's Name: I Phone#: I
ffey-bert 46 ,Cr 4
Contractor: Phone: License #:
P� 6 .: 6
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description: 1 "
Residential ❑ Commercial ❑ `
Cost of Project
Qty '
A i e Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit 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
BUSLIC Business License BUILDING