03080097 (2) CITY OF CUPER'I'INO
BUILDING DIVISIONPERMIT �&,Q �,RACTOR INFORMATION
Bu1LgINGADDRESS: CUPERTINO PLUMBING PERMITND03080097
OWNER'S NAME: 10297 S DE ANZA BLV PERMRLSUEDATE
ENA AVTNTTN
i (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH j
+oo LICENSED CONTRA R'S DECLARATION O O O O
F 1 botchy affirm that 1 am li¢iucd ruler previsions of Chapter 9(commencing Job Description
tz� with Se 70XBofDiv.k,n 3 ml rinband Profession Code.and my license is
±t2„ mmum canderrl V U REPIPE/WATER HEATER
Date Cam EG �I����®
`/ ARCHITELTSD A N
2 U 1 umdcmta�plans shall W used as public records
ca Licensed Professional SEP 22003
�O6 OWNER-BUILDER DECLARATION
aS 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p o Following reason.(SeCtiun 703 1.5,Business and Professions Code:Any city or county
<m which requires a permit m construct,alley.improve.demolish.C repair any structure
prior o its issuance.also requires the applicant for such Permit to fie a signed statement BUILDING $-on
Asa that he is lice usedpunnanuothe provisionsofthe Contractor'sLicense Law(Chapter 9 Sq, Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
d�3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 35931053 . 00
Section 9031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more thin r hundred dollars(3500). P Y YP
I.as owner of the properly,or my employees with wages as Meir sole compensation,
will do be work.and the somehow is not intended or offered for sale(Sec.9614.Business ii 7g�ytMpTT99��T�((((����
and Prefessions Code:The Contractors License Law does not apply to an owner of LYH'C6 ifIS@CCL700$
property who builds of improves thereon,and who does such work himselfor through his 502 — FINAL PL MBIN(j ENERGY
ownemployces,provided thatsuch improvemenuare notimended proffered forcale.if, SO7 — FINAL PLUMBING
however,be building or improvement is cold within one year of completion,the owner-
builder ,will have the burden of proving that he did not build or improve fur purpose of
sato.).
El 1,as owner of be progeny,am exclusively contracting with licensed contractors to
consumer be project(Sec.7044,Banness and Professions Code:)The Cunpactor's Li-
cense law dors not apply w an owner of Property who Wilds or improve mcreom,and
who contracts for such projects with a carnations)licensed pursuant m the Contractor's
License Law.
❑I am exempt under Sec. B h P C for this rearm.
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 has and will maintain a Certifca a of consent to self-insaw for Workers Compen-
sation,as provided for by Section 39W of the"her Code,for the performance of the
work for which this permit is issued.
has and will maintain Worker's Compensation Insurance,a required by Section
900 of the labor Code,for be performance of the work for which this permit is issued.
My Worker's C.okm.�pensatio/n Insurance savior and Policy numb�ejr�arm:/�, 1
Canricr.57/ka� ✓/yk�� Policy No.:'I N/VN(�
CERfIFI ATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W cmmplcwd tithe permit is formic hundred dollars(3100)
it,lose.)
1 sonify but in the Perfommmnce of the work for which this permit is med.I shall not
employ any person in any Connor m as to become subject to be Workerd Compensation
Laws of C.1iromia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
Qz forthwith comply with such provisions Or this permit shall W doomed revoked. .
Z O CONSTRUCTION LENDING AGENCY
F-' l hereby affirm that there is a construction lending agency lot he porrurmance of
x
no wink for which this Permit u issued(Sec.3699.Civ.C.)
W Under'a Name
D.
Jz Isnder's Address
U Q 1 ccnee Nu 1 bas road this application and stain that the above iws Mooing is
W F^ Condit.1 agree m comply with all city and county oulwices and state laws relating to
QU
Wildingconstruction.pimi and hembyauthonze To%futiss or the City mcnmr upon dte
above-mentioned j.unedpreperty for inxpeeuonp rposee.
F 6. (we)agree to save,mmor mfy kec umlcu the City o(Cupmim,fiabilagainst
intoitiequCaC menu.coxae wM1i may in anyway accrue against said City
U z in masequcne f gra ngu ufe '.
APPL.. SOURICA OE A 3 AND iLL COMPLY WITH ALL CNON-POINT Issued by: Date
Re-roofs
no rc of ApplicanUConu r Date
HAZA DU A ISCLOSURE Type of Roof
Will the applicant tar future huiiding occupant store or handle ho wrtim s material
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
❑Yea Nm All roofs shall be inspected prior to any roofing material being installed.
Will mea scant of future building Occupant use a If a roof is installed without first obtaining an inspection, 1 agree to remove
PP s p equipment on devices which g
obit hamidous air cnotaminanu dc0ncd by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑yes Nu
1 Wver, Chan ousm also, hremenuunder Chapari95ofthe Califmry
nia HealNKs qy Code, c4ou2 15;25 3 125534.1mmkomoddhatifthc Wilding
doss n 0 y have wnant it it u y sponsihility to nobly the occupant ortha
recut on rah w met apm6f�ofifetoofOccapm4y. Signature of Applicant Date
net r authorial seen( / / Dam mAll roof coverings to be Class"B" or better
CITY OF CUPERTINO o3
C:F REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # D72
ate:
Building Address:
Owner's Name:0,1�AI� �v/N UN Phone#:
Z�• ":71/�� (Uo8
Contractor: Phone: License #:
Cl�inE77//VG pLv�1�/�3IN �253 GCo1 �oZ�-/9� S
Contact:
Phone: Cupertino Business License#:
�t2�rNJ� C�I1GDl lh �i� Oce 1 Cod�-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
COPPi�,k
Residential Commercial ❑
Cost of Project: GDOO _
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ft
i
ID Fee Description Fee Group
E Plumbin Permit Issuance PLUMBING
Re i e of Fixtures PLUMBING
Bld . Permit Fees BUILDING
Pbl . Fixture PLUMBING
Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLJC Business License BUILDING
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