04110007 CITY OF CUPERTINO
BUILDING DIVISION PEIUMT Y Q 0 NTRACT,0 Rj NFORMATI0
BUILDING ADDRESS: PERMIT N0.4110 0 0 7
91 5) FERNGROVE, DR
OWNER'S NAME: - PERMIT ISSUE DATE
ROBERT KIRBY
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
lino LICENSED CONTRACTOR'S DECLARATION lob Description
C w I b Tri affirm Nal 1 am licensed timer provisions of Chapter 9(commencing p
U id�5 "on'BI10)of Diviskm3ofOcB Aad Professions Code.arul my license is
n'q? Decvse ClazedeUoctG b�Cu '/S6 Z� �p/ NEW 3 " ABS SEWER FOR WASHER I����®
�w CONSTRUCTION: AMERICAN LEAK D T.
CH TECTS DE, I ATION
1 understand my p ans shall be used as public reeood,
o o Licensed Professional NOV
F--- 2004
5 OWNER-BUILDER DECLARATION
a1 hcrchy affirm that 1 am exempt from the Contractors License Law for the
—0 0 following moon.(Section II31.5,Business and Professions Code:Any city or county
m which require a Permit to enrWmm,altea improve.demolish,or.,air any structure 131111 MKI
prior in its issnartce.also inquires to applicant for such Permit to rile a signed statement
Nat be is licensed pursuant to the pmvisiont of the Contractor's bruit Law(Chapter9 Sq. F[. Floor Area Q
NWOV
�0 (commencing with Section 7")of Division 3 nfthe Bisineamad Pndassinna Code)or
�^0y Out be,u exempt Nemfmm and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by airy appliant for a permit subjects to applicant to•civil penalty of APN Number Occupancy Type
not mom than Bea hundred dollars 0500). 3 7 5 3 9 0 5 5 . 0 0,
I,az owner of the papally,or my employes with wages az their sole compensation,
willda diework mathmucture is not intended oroffeted forsak(Sec.70aa,Business
and PmfetsiOm Code:rhe Cmu a mes License law dem rot apply m an Owner of Required Inspections
Property who builds or imprwea thereon,and who docs such work himself orthrough his
own employees.provided Nat such improwmenas arc not intanded oroUered forsale If,
however.the building Or improvement is cold within one year of completion,Ne Owner-
builder will have the burden of moving Out he did not build or imp dw for purpose of
ale),
❑1,as Owner of the prepeny,am exclusively contracting wit licensed convectors to
construct to project(Sec.)ryta,Business and Professions Code:)The Commences Li- _
cnue law docs not apply in an owner Of progeny who builds or improves thereon,and
who contracts for such projects with a contactor(n)licensed pursuant in the Convector's
License law.
❑1 am aempt under Sec. .B k P C for this reamn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury arc of the following declarations:
1 haw and will maintain a Certificate of Critical ro self-insure for Worker's Compete
..tion,as provided for by Section 3700 of the labor Code,for the performance of the
verb for which this permit u issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance of to work for which this permit is issued.
MyW esCompensatio��n Insurance canter and Policy number im:�
Ca er: {� S /r�A/)xa} POIt�T1g //�
CERTI i ATEOFE%EMpnON FJJIl MO WORKERS'
COMPENSATION INBOBANCE ^��� G7
(Thu action caud irm he c^mpleu4 ifte fe.i.is f rrrnchu^dred dollars(SIM)
or less)
I unify that in to perfo.manec Of the work for which this Permit is issued.1 shall not
employ any person in any mommarso as to Mcome subject to the Workers'Compenuation
Laws Of Califomia-Dao
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Escmption,you should
become subject in the Worku's Comperwtion previsions Of the Labs.Code,you must
.J O forthwith comply wit such prowinoe or tra
is permit shall be deemed nked.
?"' CONSTRUCTION LENDING AGENCY
[—i I hereby affirm tat then is a construction lending agency for the Performance of
a,1 the work for which tis permit is issued(Sec.3097,Civ.C.)
U4 Uodcc's Name
z lender's AddosI
U O 1 certify that 1 have reed this application and sum that dic about information is
ry H corms 1 agree to comply wire all tido and county O adws Of and sum laws r upon
to
a,
U shown mentioned par and hereby aton pnim rpoics. rives of Nis tido manor spm to /
4 ahovcmce) r-0,in ery..fin impaction keep :
(We)agree is ase,indemnify and kith harmless Om City Of Cupertino against
r h
liabilities.judgments.costs and expenses which may in any way accrue against old City
C)^ APPLICA nc oNthegraTANDStANDhis rWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC G
O Re-roofs
re,Of AppliemilCrntr¢mr Data
HAZARDOUS MATERIALS DISCLO RE Type of Roof
Will the applicant or fvm.building Occupant ter.orhamEemartinis mamnal
az defined by the Cupertino Municipal Code.Chapter 9.12.and the Hcauth and Safety
otic.Section 25532(e)? y
El Y. All roofs shall be inspected prior to any roofing material being installed.
�Mu
Will the applicant Or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardous air contaminants as derined by the Bay Area Air Quality Management all new materials for inspection.
District?
Yes late
Ihwere ehaaardousm=halsmquim=nuun&rChapwr6.95ofthe Califon
nu Health&Sad Code.Sec60ru25505,25533.d25534.1unJersanddutiftebuilding
does not curve Y t.that it u my responsibility to notify to occupant Of the
rein On A, si ^metprioroissuaaccrfac 111 . IOutioncy. Signature of Applicant Date
�� T All roof coverings to be Class "B" or better
Own auihonmd agent Oa.
�. Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building Department
JOB ADDRE �7/f PERMIT#
J G ✓� 1)2 < 10 o 7
OWNER'S NAME. o -T PHO #
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/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ol
r/Contractor Signature \ We
CITY OF CUPERTINO srsD�
REPIPE/SEWERSIMAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# -77-r 3 Date:
Building A)Ldress:
91 :5 F C P.,1 E, �Q
Owner's�Tame: / Phone#:
`��' e)B%e7 �, 'e
Contractorl / Phone: License #:
Contact: /� Phone: Cupertino Business License #:
fM. ,- ,A NO�) �d8 Zl0 007.7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description.
J,✓s7/l /UtJ 3 s 6✓ ✓�e (40* 4
Residential�l91 Commercial ❑
tT�
Cost of Project: ^
v
Qty. if
APP41"qdble Fee fD Fee Description Fee Group
PPERMTFFEE 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
Z( d Z