03040056 (2) CI TY OFCUPERTINO /� Y ��yy���^� �p"7"7��,,��� qptt��.�,%='
BUILDING DIVISION PERMIT rcEA+� r PMTOR TLV1C�A MATT W 4�
- BI�IIDING ADDRESS: PERMITNO.
1Q..- - VISTA DR 03040056
OWNERS NAME: 4 PERMIT ISSUE DATE
EEFE DANIEL P AND DORIS C r 04/09/2003
a: SANITARY NO. CONTROL NO.
RCHIT RCTIENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION O O
1 hereby alllrm that I xm licensed under provialons of Chapter 9(commcacol, Job Description
with Section 7010)of Division 3 of the Business and Pfofessinns Coca,and my license is
I.full force and effect.
License Class Lu.0 REPI PE/
D'te ContractorARCHITECI'SOECLARATION CONTRACTOR: E & S PLUMBING
1 understand my plans shall he used As public record
b ud�
Licensed Professional
OWNER-BUILDER won
I hereby pound.(Ems that 1 I. exempt from Ne ConlnnCc :Any c Lew far the
follop o which log uire,Apermit
t 7(13 1.3,Businer.end w.do ons Cadc:Any city or aunty
$ which my Issas a permit re cores we plug impmw,h permit t lir mash eny structure
Pr' pdormits Issuance.also requires applicant for each penult to Glc ulgned auumchi
< that he Isllansedpursuant totheprevisions ofthe Conowur'aLanmLaw(Chapur9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Divialon S of the Business and Professions Code)or
Nat he u exempt therefrom and the basis for the alleged exemption.My violation of
nSectiot 1031.5by any Applicant
or a permit subject/the applicant N a civil Formby of APN Number cupancy Type
0 I,aa oweor of the property,or my employees with wages As their able compewtion,
will do the work,and the structure is not intended or offered for silo(See.70,14,Basions
and Profeulons Code:The Conuaemes Lianse Law does not apply m an owner of Required Inspections
propenywhobuildsmortroveaNereen,andwhodoee hwakhimselforthroughhia 106 - SEWER & WATER
Own employees,pmvided I stsuchimprowmenumeno 'londea'4r�q1gfp�adfor e
however,the building or lmprowmeet week!within df to P, n,t w,N R'(3 DER LOOR PLUMBING
builds,
illhawthelaw not provingthathed1doo fid or improAFrpurposejf ) PLUMBING
01.a owner of the Property,are excluilwly,eon I g wiN1 cen¢Q', low f to—'J � OR SHOWER
consuecttheproject(Sec.7041,Bushes led Prof Code:) (U-
does Out apply we.owner orpmpenywn primnj d, NA PLUMBING ENERGY
dm SltuWA ST
a � nduS &PCfnr is on - PLUMBING
woe
3
W CER'S CO NSATION DECLA
1M by.Mm under peasl i ofperjuryoaofdm fall Ingdeclantionse
haw and will maintain aCeNOcateof Consent to self-houro for WmkefaCompen-
on,a provided for by Section 3700 of the Labor Cade,for the per(..xc of the
work for which this permit a issued.
❑1 haw end will maintain Worker's Compensation Insurssta,ss required by Section
3700of the LAW Code,for the performance of the work for which this permit is issued.
My Worker's COMPOPULWO Insurance carrier and Policy number am:
Center: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Thu section need Out becompo tad lion pant h is Him hundred dollars(SIM)
Or leas)
1 aNfy thal in the performance of the work for which this permit is owed,I shall nm
employ any person in my mmner an as to become subject to the Warkers'Compensation
Laws of California.Dau
Applicant
NOTICE To APPLICANT.IL Her making this Certificate of.Exemption,you should
become subject to the Worker's Compensation provisions of the labor Cede.you must
.,O forthwith w
with comply with such provisions or this permit shall be decreed mkrd.
y CONSTRUCTION LENDING AOENCY
1 hereby wick thi this Nemuaammc.307,Ch, .) for the Performance of
Y� Newark far which Nb permnH Wad(Sec.7097,Civ.C.)
Q Lender's Name
z Lender's A!lress
L)Q I certify But 1 haw mad this application and State that the.bow Information is
correct.I agree to comply with all city and county ordinances and eau laws relating N
U building construction.and hereby aulhOfIM roIAOSMIdiwa of this city lb enter upon the
W abow•mcntioned Property for lnspecdon PurPOWL
(We)agree N taw,indemnify and kap harmless the City of Cupertino against
r rrAA Ilabllitia,judgmenu,costs and expemes which may in my way anise agalnstsaid City
f the
J APP ncaUN EA Sterling ofthis
Permit.ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE LATIO S.
Re-roofs
n fAppliem meet r a '
HAZARD MATERIALS DIS OSURE Type of Roof
Will tht applicant or future building uccupanbtom or handle haasrdous materiel
As defined by the Cupertino Municipal Cade,Chapter 9.12.end the Health and Safely
Code,section 25332(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yet No
Will thea licant ar fuuro If a roof is installed without first obtainingan inspection,I agree to remove
M g aeupant use equipment or devices which P g
barndnus air antamlnants as!shied by the Bay Arta Air Quality Management all new materials for inspection.
Iritn P
❑Yes p19�
I how mad thehvi ummaurlaB ulmmcnts under ChePurd.93aflheGlifor-
nieHnot a
37(15.25333.P 4.ImWemm�dc,unif
occas Wildingdaca not at ltl y W "IllyIy the aecuP�nlMNculmm nut u a nifmate mmnature of Applicant Date
D, All roof coverings to be Class"B"or better
CITY OF CUPERTINO o )
REPIPE/SEWERS/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
Building Address: I (' T7�/•��
Ow r' a`me: Phone#:
- Z- 33
C c �2 Ph e: License#:
C ntact: Phone: Cupertino Business License#:
— 2 —
uilding Permit Info.
_-
Bldg ❑ Elect ❑ PIU96
Job Description:
Residential -.. 70r-- ' rl. . -
Cost of Project:
J /
Qty if
A i'ble Fee ID Fee Description Fee Group
PPERMUFEE 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 Dis osal PLUMBING
BUSLIC Business License BUILDING