04050167 CITY OF CUPEIIT[N0
BUILDING DIVISION PERMIT ^CONTRACTOR INFORMATION -
.
BUILDING ADDRESS: TOM ' S PLUMBING PERMITNOO 4050167
ANY rT
NER'S NAME: PERMIT ISSUR DATE
ANELINE CHI P
NE:
SANITARY NO. CONTROL NO.
(408) 867-6010
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
.0, 'LICENSED CONTRACTOR'S DECLARATION Job Description
o p
U❑ 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
iW with Section fNIU)ofDivision3ofNCBusiness PmRsamisCode.andmyliccmmis ��nry
is rtru mra fifers. 9 / GAS LINE FROM METERTO Lotti pL �G�II'Ti`E�®
?vvcaji License ClLick
n F p Dale, r Canlr'r
e AR HfIELTS DECt.�p
Ym 1undc'ran myplansmudlhetiredaspuhhcm CJs JUL 6 2004
Dwc
}C.
u Licensed Pmfcssienal
`0 OWNER-BUILDER DECLARATION e
1 bereby aRrm Nat 1 am exempt Imm the Convectors License law for the ��ria RQ���t�0�
00 following resson.(sectiun](1I1.5.Businmfe
ess and Pssivas cafe:Any city or county Otl
;4$� which myuiru a permit to eonswn,she,improve,demolish,or repair any shoctum
prior to its issuance,also requires the applicant for such permit to file a signed statement
—i<
that hcislicensed purxntnotheprovisionsoftheContractoriLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation
m
z1- (commencing with Section 7")or Division 3 of am Business and Professions Codc)or
that he is exempt Nerafrem and tk basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to•civil penalty of 3 6U7NG41Qaer0 0 Occupancy Type
not more than live hundred dollars(5500). _
01,mownerofthepmpeny,ormyemplo with"guuNeirmlccompensmim.
will do @ework.and the structure Is not intended oro«ered for sale(Sec.7044,Business
and Pretexts..Code:The Oomacters Lieenm Law dors.1 apply m an owner of Required Inspections
property who builds or i mprovu Nerenn.and who does such work him.1 r or through his
Own employers.provided that such improvements arc not animated oroRered fnrsme.If.
however,the Wilding or'unpmvement is mid within one year of completion,the owner.
Wilder will have the Warden of proving Chat hr did not Wild or improve for purpom of
sale.).
❑1,as owner of the propeny,am exclusively convecting with licensed contractors to
construct the pmjea(Sec.7044,Busineas and Professions Code:)The Consumer's U.
.Law dors not apply or an owner of property who Wilds or improves themon,and
who contracts for such projects with a contractor(,)licensed pursuant to the Contractors
Liceve law.
I sonexempt trade,Sec ,B&P C for thin mason
137M
r Das
WORKER'S COMPENSATION DECLARATION
1 hereby"M trader penalty of perjury ooe of the following decimations:
nce and will maintain a CCrmfiate of Co.cnuosal6iasure fez WerkrraCompcn-
,u provided for by Sation 3]00 of the labor Code.fm the performance of the
for which this permit is issued.
have and will maintain Workers Compensation Insurance,as required by Section
of the labor Code.for Ne aformance of 1M work for which this pmrit is issued.
orkdC; ompeww�a Insurance anise and Poli numbcrta
ec r/An�xCE Polity
CERTIFlC O OF COMPENSATION
INN FROM WORKERS'
COMPLNSATIONINSURANCE
(Ibis section food not W completed if the permit is for one hundred dollars(5100)
or Nes.)
I unify that in the performance of Ne work for which this Permit is issued,l shall not
employ any When in any manner an u to become subject o do Wohcr%Compensation
Laws of Califomia.Data
Applinm
NOTICE TO APPLICANT:IL after making this Ccnificate of Exemption.you should
became subject to the Worker's Compensation previsions of the Labor Cade,you mum
.J O forthwith comply with such provisions or this Pamir shall W ateemcd revoked.
Z� CONSTRUCTION LENDING AGENCY
tw Thereby affirm Nat there is a conmuction lending agency for the Performance of
W> the work for which this permit is issued(Sec.3037,Civ.C.)
W ^n- Lenders Name
L1. lenders Add.
U Q 1 anify that I have read this application and sum that the about information Is
W f" correct 1 agree to comply with all city and county on iner as and sum laws relating to
QU building construction.and hereby authorize,repreunutives of this city to enter upon W,
}(w above mentioned p openy far inspection purposes. y�
(We)agree to save,indemnify and keep harmless Ne,City of Cupertino against
FTN Rabilitiu.judgments,cos and expeues which may in any way secmc against mid City
U Z APPL CANTeUNDERSTANDS ACND W Permit.L COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE REGU ONS.
�� rO Re-roofs
I reef Ap canUComactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne,applicant or future Wilding occupant shore or handle heu emus material
as defined by the Cosentino Municipal Cade.Chapter 9.11.and Ne Health and Safety
.Seericm 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will thea applicant or future building t ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
rap s coupon gtripmen
emit havardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes MNu
1 have real the Washbous materials requirements under Chapmrb.95 of Nc Califon
.is Health&Safety Codc,Secuo.255)5.25533 and 25534.1 ten crsund tradthc Wilding
Joca not currently have a tenant Nat it is y responsibility w notify the u:e.,anm of the
Ccqulrcm .which mheme,Pr w tr'CC oracc'r'C rorwaPamey. Signature of Applicant Date
Zrd 6
Own authofi JaFem Date,
All roof coverings to be Class"B" or better
' �.p
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
ISCITY OF Fax(408) 777-3333
CUPEkTINO
Building De axe
JOB ADDRE /032 Dom/ PE IT # ou go
I f
OWNER'S NAME: ,e h— PHONE 1 b
GENERAL CONTRACTOR:' FAX #
I am not using any subcontractors:
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/ Walfpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
e /Contractor Signature Date
10/28/03
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # / Date:
- 2Q, 0
Building Address: pp
2 cJi .
Owner's Name: Phone#: 7-�
CQntsast9r. Phone: License#:
o $6 ? & a U 667l
Contact Phone: Cupertino Business License#:
-Aro—?— cooly11
Building Permit Info:
Bldg a Elect ❑ Plumb
Job Description:n
-1,.s �xv � (-I e `rk<1 Lo L,s
Residential Commercial ❑
Cost of Proj o
e
Qt if
AKplitable 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
BPS E Sewage Disposal PLUMBING
LIC I Business License BUILDING
�Gg 7- 5^�