05010027 CITY UI'CUI'LwrINO '
11111111111c;DIVISION PERMIT CONTRAGORINTORMATION .
B
UILDING ADRPss: CAL-COAST REPIPING, INC . PERMIT NO.05010027
7
NER'S NAME: PERMIT ISSUE DATE
ILOUISE SCHOOLEY 1371 TITAN WAY ni /oc;/2noc;
NE: SANITARY NO. CONTROL NO.
714) 578-5090
ARCI{IILCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
fop LICENSED CON'TRACTOR'S DE,:AL"ARATION'.
F❑ nnere affirm Ilial I am licensed unJm si n(chaplcr 9(commencing Job Description
�iW with agB of Division 3o(thc Buaincv and PM2isinns CoJc,end myliccnsc is
in full eanaerr .t. 63rry REPLACE PORTABLE WATER LINE (HOT/COLD)
1�0 Lice7 Conti
M1 p DaN, S C Cunlractor
ARCHITECTS G1tAT1'�
I un ars n lana shall W us J hlic j
�pN Licensed Pmn
fcss
OWNER-BUILDER DECLARATION
aS I hereby arfirm that I lam exempt from the Contractor's License Law for the .tom•
.
00 following reason.(Secuun 7031.5,Business and professions Code:Any city m county V
<m which mquima permit to consumer,alter,improve,Jemuh,4i.err repair Any elmnure
prior to its issuance.alsu requires the applicant forsuch permiuo Glc axignedsulemem
6 that he islnenscJpursuant tothe provisions ofineContractor's License Law(Chapter 9 Sq. Ft. Floor AreaValuation
21=-0 (commencing with Section?0001 of Division 3 of the Business and Profusions Court or
that M is exempt therefrom and the buffs for the alleged exemption.Any violation of _$4200
Section 7031.5 by any applicant for a permil subjects the Applicant o a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars(5500).
❑1,ati owner of'tie propemy,in my employees with wages As mcir salt compensation,
will do the work.end the sroaum is not intended or offered run {See 7044,Business
And Proreaaions Code:The Contmcton's License Law does not apply Io an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended oraRered foraale.If.
however,the building or improvement is sold within one year of completion.the owner.
Wilder will haw the burden of proving that M did not Mild or improve for putpose of
sale.).
❑1,as owner of the property,am eulusively contracting with licenard contractors to
construct the project(Sec.70,14,Business and Profusions CWc:)The Contractori Lt.
cense Law Jas not apply 1.as owner,of pm,oy who Wilds or improves Neuron,and
who contracts for such projects with a conmeror(s)licensed pursuanno the Contractor's
Licem a law.
El 1 em exempt nodes See. .B&P C for this mason
Owner Daa
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dalaralions
have and will maintain a Cenificam of Consent to xlbinsum for Worker's Compcm
ration,As provided for by Section 3700 of the Labor Code,for the performance of the
work for which Nis permir is issued.
❑I have and will maintain Wmkcra Compensation Insurance.as required by Section
3700 of the labor Cole,for the performance of the work for which this Permit is issued.
My Wmkc' mm nsalion Insurance carrier and Policy nylq 11
'1 Cartiee Policy No.: /a D
CER I CATEOF FROM W
OKERS'
COMPENSATIONIN FROM
section need not be completed if the permit is intone hundred dollarx($1 W I
or lux.)
1 certify that in the performance of the work(or which this permit is issued.I shall not
employ any portion in any manner x az an become subject to the Workeri Compcualion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mus
Z forthwith comply with such provisions or phis Permit shall W deemed mvlaked.
Z O CONSTRUCTION LENDING AGENCY
I hereby aRrm that there is a comem clion lending agency for the performance of
x me work(or which this permit is world(Sec.3097,Civ.C.)
y Q LendlL
er's Namc
7 Z Lender's Address
J 0 1 certify that 1 have read this application aM sate that me shout inflammation is .
(^
come,.1 agree to comply with all city and county ordinances and stale laws relating to
V building construction.and hereby sudannive mInexnaaws of mos city'.carer upon the
�Ct]
'how-mentioned property for lnspenion purposes. -
gy (We)agree to saw,indemnify and keep harmless the City of Cupertino against
p3 Iiabiliues.judgments.costs and external which may in any way acerae against said City
J z inconxganee of me graining of this permit (\
^ APP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO R E REGULATIO
Re-roofs CIt.
n contractur �--�
HAZARDOUS MATERIALS DISCLOSURE`' are Type of Roof
11 the Jur applicant or future building Occupant store or handle ha'ran amts material
as defined by the Cupcnino Municipal,Code.Chapter 9.12,and the Health and Safety
Calc.Section 25533(.)? All roofs shall be inspected prior to any roofing material being installed.
❑You
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
hazardous air contaminants u Jcfncd by the Bay Arca Air Quality Management all new materials for inspection.
,vitt?
❑Yu KN.
I have mad the hanN'ws materials myuimmenu under Chapter 6.95 of meCalifon-
nix Health&Safety Code,Sccumn 255)5,25573 and25534.1 undersand thm if me Milling
Jas nm -have a ananr, a1 it is my rosponsihiliry Its anal,the aeupant of the
rcyui ichmustbem p' raissnaneelar ic.te.r cup e. Signature of Applicant Date
owrierorau, dredAllen t All roof coverings to be Class"B"or better
a Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
6UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
- z i S
OWNER'S NAME: PHO G& 7
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature ate
Please check a m applicable subcontractors d complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
A
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing 4
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature bate
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICECITY OF
CUPEI�TINO PERMIT APPLICATION FORM
APN # Date:
32 6 I o 6
Building Address: I
22331 n Ie- +
Owner's Name: Phone
V. , e . 2 77
Contractor, Phone: License #:
Co.l goo S► 1 G
Conta • Phon Cupertino Business License#:
q� lG l9 -G 773 2 2
Building Permit Info:
Bldg- ❑-- Elect` ❑ Plumb'
Job Description:
Residential XCommercial ❑
Cost of P Iect:
0
Qty. if
App I 96-b-Ie) Fee ID Fee Description Fee Group
1 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
Z $ � 7
e