05020172 CITY OF CUPERTINO r? ? ats
BUILDING DIVISION PERMIT CONTRAC-TORANFORMAT ON':=
BUILDING ADDRESS: WATER QUALITY PLUMBING PERMIT N005020172
1609 POPPY WY
OWNER'S NAME: PERMITISSUEDATE
WINSTON SHIAH 1860 ALMADEN RD 02/24/2005
ONE: SANITARY NO. CONTROL NO.
(408) 267-9330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
jas LICENSED CONTRACTOR'S DECLARATION Job Description
1 Mosley affirm Thu I am licewd under previsions of CMpter 9(commcndng .
Ith Seatim.7000)of DivtaionJofdm wiM••and Profeuiom Code.and mylicew is
+� Lmnmreeand —p f REPIPE/MAIN WATER LINE
j P�12o License Clw
J Dam
Cantndor .
e CHITECTS DECLAR TI /1
` 1 undemlend my plain shall he mud as public mcnNs 1//lf/y—D rrr���
e LL
Licensed Professional
y re Oat I am exempt
from
DECLARATION the
CO q I marry affirm sect that I 1 .umpl from Ne Contractors License Law for
COD o following mann.Permit
t ]1DI3,Business and ve.de nu Code:Any oily or county I'
m which inquires n permit re quires cL alma impmsu demolish,rarerepair lige rl ttrucl11tonum !7� 4 5 0 0
3—y
that he
itsi.suance,al-mquims throiulo s.r for suchPermit to rile Law statement y
2 0 that mencicenmd puration70hc pmvisinna of the Canwcess i Professions
(Chapler9 Sq.F[. FIO(� ea Cf�/a� Valuation
'at
is examwith Seglonl(100)th Division]ns he Business andon.Any
or /Q Op� � g/
� .. Net he is exempt them(rom and the breis for Ills alleged exception.Any vl0latlon of ( �f/
Section 7031.5 by airy applicant for a permit ubjects do epplkanuo•civil Penalty or 'g &a to �� Occupancy Type
no,mart than firs hundred dolt..($500). (�/f l
❑1,u ovou of the properly,or my employ=with wages u thele sole compew0on,
will do the work and thcswaurt into.intended er oRcmA fonaie(Sce.]0a4,Buainw Re uired Ins ecfions
sed proposed.Gene:The Contractors Licaw Low d=not apply b an owns,of q P
property who builds or improves demon,and who doe.such work himself or though his
own employ=.provided Out such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year or completion,me owner.
builder will have the burden or proving that he did not build or Improve for purpose of
salaJ,
D L as Owner of the property am exclusively contracting with licensed contractors to
construct the pmJect(Sec.7044,Business and Profession Cade:)The Contractors U.
cone Law docs not apply in-owner or property who builds or improv demon,and
who contracts for such pmjecu with a contractor(s)licensed pursuant to the Contradoh
Lice.law.
D lam exempt under Sea. ,B&P C forthis moon
owner Dete
WORKER'S COMPENSATION DECLARATION
1 hemby salon under penally of perjury,one of the following declarations:
I have and will malwln•CeNBcate of Cowin to self-imum fm Worke's Carrico-
-tion,u provided for by Section 37M0(do Labor Code,for ft Performance of de
work for which this permit Is issued.
❑I have and will maintain Workers Commasallrn Insurance,at;required by Section
3]00 of de Labo Code,for de peRormuce of the woh forwhich.this permh�ssned.
My Wnrker'sc penallo.lmm�n cln.ro..dP iirynuwbIc D
Cartier. - Policy No.:�.L.[,rj5p,J �
A F PnON PROM WOR RKE 5
C PENSATION INSURANCE
(Thtseelion need nothecornplebd Ethic Permit IS fmonehundrtd dollans($100)
or Mss.)
I certify that in the performance or the work for which this pmmll 4Issued,I shall not .
employ any person in any manner an as to become subject m LOU Workers'ComMnalion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,a0er making this Certilcae of Exemption,ynu should
became subject in do Worker's Compensation provisions of de labor Code,you most
0 O forthwith Comply with such provision or this Permit shall le dcemed invoked.
ti CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a mutmNnn lending agency fordo performance of I'
x?,r the work for which this per=il is issued(Sec.3(197,Co.C.) -
31 Q Le d1l,'a Name
z Lender's Add. -
J Q I acetify that I have=d this application and tum not me above information u
y conecL 1 agree to comply with ail city and county on iw ces and sok laws mining to
building convection,and hereby suthotiw representatives of this City to cnbr upon[be
W alrovancmioned property for impaction pugeace `
(We)agree to saw.Indemnify and keep harmless the City of Cupertino against
ti y
liabilities.judgments.cats and expenses which may In any way accrue against mid City
In consequence of the grading of this permit. v'2/
F7 APPLICANT UNDERST NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU TIO
02 'z Re-roofs
SignturerAriplicarX.m.mr D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwm building occupant atom or handle ha-Nous mabrial
as defined by the Cupertlea Municipal ,Charter 9.11.and the Health and Safely
Cod.,._-tilos 25532(e)7
j_-1 yes All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future Wilding=open,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It ha-ednn air tomaminatn u del do Bay Arta Air Quality Management all new materials for inspection.
strict?
Dyes' u
Ihaw mad Codc,She on mab0525qulrtmcnuundcrChepundurmifmc Gelding
ret Heald&Saigty Cadc,Scctiu 15NI5,$577 uJ 255]4.1 understand dot if de building
Jas not cunen0y he a b 4 da my rce lily m notify the Occupant Cline
mgmm nawhi st1pri Ulm cad ac rnin-boroccup-cy. Signature of Applicant Date
owner— ra�,<d�em Dale All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEI�TINO
Building De artment
JOB ADDRESS- PE�IT�kO� D//H�g
OWNER' NAME: PHONE#
GENERAL CONTRACTOR FAX #
I am not using any subcontractor . 02
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
Z4Signature Date
CITY OF CUPERTINO Q /,- a` 72-
OREPIPE/SEWERS/MAIN SERVICE J
CUPEkTINO PERMIT APPLICATION FORM
APN# 3& Dater a
Building Address: /i •O v P,0` ^,/1
Owner's Name: ! i'tj�� (/ Phone#: ,
Contractor: . Q i/ / Phone:� p�SP n 33D Li c e#: �l4
Contact: Phone: C "' Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
elr &P" ) YY) Q l h ► Y)
Residenti Commercial ❑
Cost of Project: LP 5D O 0'0
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
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
2,V
7 .