04030228 CITY OF CUPERTINO �� TTQ I dt1Ya ; .
BUILDING Drvlslory PERMIT rtv,leV
_ 5
BUILDING ADDRESS: PERMIT NO.
PRO ROOTER 04030228
OWNER'S NAME: PERMIT ISSUE DATE
ALLEN NE: SANITARY V @01401,N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDOELECT PLUMB MECH
0 0 0 0
oo LICENSED CONTRACTOR'S DECLARATION Job Description
ie U I l areby aMou that 1 am licensed under previsions of chapter 9(commencing
< with Section 7000)of Division 3 of the Business and Professions Code.and my license is
^ � In full farce and art=[. f �yD/ z_ REPLACE SEWER LINE
t,m License Class
Da �'NALED
A,- le Contractor. ■
ARCHITECTS DECLARATION
I understand my plan.shall he used as public ons,m]s MAR 2
,� 8 2004
C Licensed Pmfessioml
OWNER-BUILDER DECLARATION
1 hereby aflon Nat 1 am exempt from the Comnctor5 License Low for the BUILDING
0 O following reason.(Secdun 7(01.5,Business and Profusions Code:Any city or county
$ which contras a permit to construct,altar,Improve,demolish,or repair any structure
F < Pdono its issuance.alae rolulret theapplicant fuum.h Permit 1.RIO astgncdstatement
£ Thu he I.licensed prrumncto the proviaiomoftheContramrsLimnseLaw 0M.Pter9 Sq.F[.Floor Area Valuate 0
y�m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or _
$
that he k naerept therefrom and dW buss for the alleged exemption.Any violation of
Section 7031.5 by airy applies^,for a permit subjects the applkantto a civil penalty of 3WR1$'bt8*er00 Occupancy Type
not more thsn five hundred dollars(5500).
O 1,as owner of the proprtty,or my employees with wages u their sok compensation,
wiildolhewmk.utdtheaumue lsnotimmndedoroffered farsale(Sm.7044,11minw Required Inspections
and Profession,Code:The Conhaeme.blame Law does nut apply W an owner of q P
property who builds or im pmvu thereon,and who does such work himself or through his
own employees,provided thmsmh improvemew arc n amounted oro@red fornk.IL
however,the building or improvement is sold within ore yeti of compkdon,the Owner-
builder will have the burden of proving that he did not build or improve for purpose of
oalc.).
❑I,as owner of the property am exclusively contracting with licensed convectors W
construct the project(Sec.7044,Businw and Profwlom Code:)The ConisscWrs Li-
entire law does not apply W an owner of property who Wilds or Improves thereon,and,
who contracts for such projects with a conuactar(s)licensed pursuant W the COMon eS
License law. _
❑I am aemp,under See. p .B&P C fur this mason
tC331'W
ner X 7d 0 2 Data 3
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemity of perjury one of the following decla spoor:
1 have and will mention a CaNfiesW of Conant W sel6insure for Workers Compcn-
kn,es provided for by Sued..3700 of to labor Cade,for Ne performance of the
Weak for which this permit I.Issued.
1 have and will maintain Worker's Compensation Insurance,u ou uimd by Section
of tho labor Code.for the performance of the work for which this permit is issued.
y Workers Compensation Inuuance carrier and Policy number am:
Cartier. !VP Qd/rT/A6Poliq No.: 6U r-X 9)0 Z
ERTIF CATE OF EXEMPTION n0M WORKERS'
COMPENSATION INSURANCE
(Mia section reed.ml ccompl.wd ifthe Permit Is for one hundreddnllars(5100)
or Icsa)
I cenify that in the performance of the work for which this Permit is iuved,l shall not
employ any Person in any mama an as W bmomcsubject W the Workera Compensadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If, four makingCenificale of Exemption,you should
become subject Ice the Workers Compensation provisions of tha Labor Code,you most
,JO forthwith comply with such provisions or this Permit shall be deemed revoked.
z h CONSTRUCTION LENDING AGENCY
[-t Thereby afrmthat Nero is.comtmction lending agency for tW perfurmanm of
(Yr 1 : the work for which thk Permit-Hpexxd(Sm.3097,Civ.C.)
WQ Lender's Name
0.z Lender's Addres .�—
U Q 1 cenify that 1 have read this application and slam Nu the be.Information is
F conch 1 agree to comply with all city and county ominamca and Stam laws minting W
O V building conmuction,and hereby outhouse mprcwmxtives of this city 10 enter tarn^Ne
r a above-recndoned property for impaction purposes.
F (We)agree W save,indemnify and keep harmlw Ute City of Cupertino against
y Iiabilitiu.judgmcnLL.coats and expenses which may in any way acme against mid City
U 7 in consequence of the granting of this Permit.
P APPLICANTNDE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
y SOURCE REIA S.
�1 Re-roofs
SignaW n ntrscmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantatom or handle hemmous material
ua dofined by the Cupertino Municipal Code.ChaPWr 9.12,sad the Health and Safety
Code.seat m 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
-0%N - ONO
-
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
mit harardner air contaminants u darned by the Bay Area Air Quality Management all new materials for inspecti
Disrricl�
❑No
I have mad the haamous materials requirements under Chapter 6.95 of the Califor. flj
nia HesW&Safety Code,Scedom 25505,25533 and 255341 understand that irtha Wilding (/
does not cartoon,hew a Wnam.that it is my responsibility W nom'y the recut.'of the
reyuiremcnb whi 51 Cl prior of CCN6cate Or Ocrz cup cy.
E fv� Signatu t ate
owner wata All roof coverings to be Class"B"or better
Community Development .
10300 Torre Avenue
r Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEI�TINO
Building Department
JOB ADDRESS: 22 PERMIT # 003 0 L2,
OWNER'S NAME: PHONE # S i 7ssoi y r
GENERAL CONTRACTOR o �— FAX #
I am not using any subcontractors:
t a e Dat' es'"/
Please check applicable subcontractors ancom Tete 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
7�— Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
'� .
Owner/Contracto gr. a Date
• CITY OF CUPERTINO -24
REPIPE/SEWERS/MAIN SERVICE °
0
CUPERTINO PERMIT APPLICATION FORM
APN # 36-6- ldp e:2,2 Date: -21 L/
Building Address:
Owner's Name: V Phone#: 1
D
Contractor: >� Phone: License#:o� —4zS
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb'
Job Description:
Residential , ' Commercial ❑
Cost of Project:
Qty. if
Applicable 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