05020175 CITY OF CUPERTINO
BUILDING DIVISION PERMIT aC,ONTRACTQRINF.ORMATON
BUILDING ADDRESS: CUPERTINO PLUMBING PERMIT"b5020175
Adl742 DRAKE CT
OWNER'S NAME: PERMIT ISSUE DATE
YAY & CHARLES T14ompgnm inqq7 q T)p. AmzA RTV I /2�/900c�
ONE: SANITARY NO. CONTROL NO.
408 253-0618
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
_Oo LICENSED CONTRACTOR'S DECLARATION
�im FC 1 hcnby )of Net 1 am licensedBu under provisions Of Chapter 9 mylicc=is Job Description
W with Srotion70fIU)of Division Softhc Busnras and Profcasium Code.admyliccmc is
7v? nmufo—Inde r� V U REPIPE
License Class = Lie.N
zF O Dam Cpnbacom
EE'Js ARC HTTECTS DECLARATION
�i C< I undersand my plans shall be used as public rtetoo
JyU
iii Licensed Professional
OWNER-BUILDER DECLARATION
P I hereby affirm Nal 1 am exempt from the Contactors License Law for the
Eno following mason.(Section'103 L5.Business and Promotions Cade:Any cilynr county
E
m which myuifes a permit to construes,ahs,.improve,demoliap,or repair any shucwn
m�'^ prior to its issuance,alas re thine the applicant forsuch permit to file a signed summnt
ESGthat he is licensed pursuantto the previsions of the contactors lJttnse Law(Chapter9 Sq.Ft. Floor Area ValuatlOn
ml-' (commencing with Section 7")a Division 3 of We Business and Professom Code)or
i that he Is exempt Cmefmm and the basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 14aaQNIltt�ei0 0 Occupancy Type
not mon man five hundred dollars(S5BD). P Y YP
L as..Or of Ce property,or my tmploycn with wage as their In camper athm,
will do the work,and thesmucmm u not intended in pfamd for sale(Sec.Iliad.Business
and Professions Code:The Onormtori License law don nm apply to an owner of Required Inspections
property who builds or improved Herron.and whodoessuchwork himself orlArough his
own employees,provided thm such improvements am not intended oronered forsain.If,
however,We building or improvement is sold within one year ofcomplebon.the owner-
builder will have the Wrden of proving that Ito did not build or improve for purpoa or
a1eJ.
❑1, a Owner of ct properly.am,Business
contacting with:)The Cc9nua:toato T.come,La the project(Sec.7W,Business and property
wh ions Crede:)The Contractors n /
who contracts law dors not apply e ts owner of property who builds or improve Corton,and
whoseLa .for such projects with acmnwemrts)IiarLmd pursuant in the Contnnors
Licen01. veto.
❑1 am exempt under Sec. .B&P C far this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peonlry of perjury one of the following declarations:
I have and will maintain a Cenifieate of Conant to self-insure far Wofbef's COmpen-
adan,as provided for by Section 3700 of the Labor Code.for the perfarmanw of Ne
work for which this Permit is issued.
❑ I have and will maintain Workers Compensation Insu once.as mquimd by Section
3700 of the labor Code,for We performance of the work for which this pemtit is issued.
My Worker's Compemation Inmanee carrier and Policy number arc,:.�✓�
Cima,4�lE-�+ s_ Policy No.: `7lj0CVJ /GU .
CERTIFl ATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complemd dine permit is for.hundred dollars(SIM)
or lila)
1 Unity Nat in the knrom,arme of the work for which this permit is icemen,I shall not
employ any Person in any manner sed as to become subject to the WorkerCompensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become suhjcct an the Worker's Compensation provisions of the Labor Code,you must
.,z foMwith comply with such provisions or this permit shall be damned mmkcd.
Z O CONSTRUCTION LENDING AGENCY
Ihernia, M.Wt fm isacomortician.lending a get,for din arfurmace of
a dm work for which Nu Permit at issued(Sec.397,Civ,C.)
1 A Under's Namc
z Under.Address
U Q 1 certify that 1 have mad tons application and sato thm the above inCm to on is
IT.F cos¢cL I agree In comply with all city and county ordimnms and sum laws rtlating to
0 building construction,and hereby authoda mpresenmtives of this city in color upon the
r 4[1 above.mentioned propeny for impcction purposes.
Fgy (We)agree to ave,indemnify and keep harmless Ne City of Cupertino against
' rA Intuit6es,judgments.coats and exhausts which may in any way accrue against aid City
C..3 z in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND
W_ LL COMPLY WITH ALL NON-POINT Issued by: Date
S�TA
A �� Re-roofs
SiBroilincid!PlipiflirolloCaltyllium Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tht applicant ser future building Occupant nam or handle haafdous reamnal
az dcfincd by the Cupertino Municipal Code.Chapter 9.12.and die Health and Safety
Ad1wood.S❑Uroedn 255324)? ❑Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or filum building occupant use equipment or deviate which If a roof is installed without first obtaining an inspection,I agree to remove
cm It havafmps air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Cl Yes ONO
1havenalthehv msmamrialsmquimmentsunder Chapter6.95oftheCalifor-
nia Hnith R Safay Code,Smvom25505,25533 and 25534.1 undemad Cat if the building
Jon not curten0y Aaw a moat.Nati y msponsihility m notify dm Occupant of the
mquimments me R ma r.ccmrmamoroccupincy. Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner ser uNonrcd agcm '- Dam
Community Development
10300 Torre Avenue
y Cupertino CA 95014
b J Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: M 7;)-7 G PERMIT OSd Z 3175'
OWNER'S NAME: PHONE # yq(> //'/Cl
GENERAL CONTRACTO : FAX #
I am not using any subcontractors: /
Signa Date
Please check a licable subcontractors a com Tete th o owinginformation:
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 n
Tile
er/C act e-
Date
CITY OF CUPERTINO S�v a o / 7,51
REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# /YJ I U /71G . ()I -S- Date: Z . 2 J U
Building Address:
1g7goz make Ct
Owner's Name- Phone#: nqb
It ,0-73)
Contractor �
. Phone: License#`/
✓�a � 253 bCo I �2 or
Contact: I �Ll I Phone: Cupertino Business License#:
ZSR o� Cora
Building Permit Info:
Bldg Elect `D Plumb L7
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