04010005 CITY OF CUPERTINO
t BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDINGADDRESS: PRO ROOTER n PERMIT No 04010005
' OWNER'S NAME: PERMIT ISSUE DATE
ROBERT
ONE: - SANITARY NO. CONTROL NO.
(510) 670-1115
1� flh
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
otLICENSED CONTRACTOR'S DECLARATION -
@zI hereby arum that 1 am nanxa ander previsions of Chapter 9(commencing lob Description
n2Section 7000)of Division 3 of the usi ssandP sionx rade,grad yliccnx is
wlm acme >.�. d// REPAIR SEWER LINE
�� Lice. Lic.N
No o Dau
e I ARCH SDE ATI
y. �ndcrsund my plans shall On used as public mmnLs
;,H Licensed Proresawnal l i
g OWNER-BUILDER DECLARATION t
.�<E I hereby affirm that I am exempt from the Contractor's License Law for the
m 0 following reason.(Section 703 1.5,Business and Pmrcashms Code:Any city of county t
1.4 which requires a permit to construct,alter,improve,demolish,or rtpair'any structure ,I
=40 prior to its issuance.also requires the applicant for such permit to file a signed statement
ggmma that he is licensed pursuant to the previsions or the Contractors Liccnx Law(Chapur9 Sq. t. Floor Tea Walua[ion
yFo (commencing with Section 7000)of Division 3 of the B usiness and Professiar -
a $ Net be is escmpt thcrefmm and me baso for me alleged exemption.Any=of poi n.n
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3'A'B19i@�7r�er00 OccupancyT e
not more has five hundred delta.($50)). YP
I,as owner of the pmperty,or my employees with wages m their sale compensation,
will do t1e work,and the sltacture is not intended or offered for sale(Sec.7044,Business
and Pmfessions Cade:The Contractor's License law does not apply to an owner of -Required Inspections
property who builds or improves thereon,and who doessuch work himselfor thmugh his
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement Is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7(l44,Business and Processions Code:)The Contraclor's Li.
cense Law does not apply to an owner orpropeny who builds or improves themon,and, -
who contracts for such projects with a cmnmc oos)licensed pursuant o the Contractor's
License Law.
❑I am exempt under Sea ,B&P C for this muon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of pequry one of the following declarations:
I have and will maintain a Certificate of Consent to self insum for Workers Curr en-
sation,a provided for by Section 37011 of me labor Cade,for the Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation insurance,as re piimd by Section
3700 of the Labor Code.for the performance or the work for which this permit is issued.
My Workera Compensation ranacamicr dPolic n,,krau: �fys
4'e aliryw�x"�/s�Z_
RT IC TE PTION FROM WORKERS'rgy_fl'D
QrC�MP ATION INSURANCE
This roti n rad not M completed if the Permit is for one hundred dollars a100)
nr leas.)
I certify that in the performance of the work for which this Permit is issued,1 shall nut
employ any person in any mannerso as He hecottte Subject o the Warkeri Comperuation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making Nis Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of me Labor Code,you must
.J O forthwith comply with such previsions or mix permiuhall be deemed..ked.
Z CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for Be performance of
Rai > the work for which this permit is issued(Sec.301 Civ.C.)
W� Q Lenders Name
Q z Lenders Add.
U Q 1 certify Nat 1 have read this application and ruts that me above mfunrXima is
com
iy H cct.1 agree to comply with all city and county ordinances and suu laws uladng to -
Q C.) building consouction,and hereby autharim rcmesenuaLMS or this city to enol upon the
above-mentioned p rperly for impection purposes.(We)acme to save,indemnity and keep hay in an the City ru Cupertino against ( /x
C4 liabilities,judgments.costs and expenses which may in any way accrue egainxuid City
t) z in co quence of the gran ting of this permit.
ti APP (CANT UN RSTA14DS AND WILL COMP WITH ALL NON-POINT Issued by: Date
IMT,
NS. �l
G'Y% Re-roofs
IMT,
LZWof Applicant/Conlncmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uccupam pore or handle havemous maudal
as defined by the Cupertino Mlmicipal Code.Chapin 9.12,and the Health and Safety
Code,Salton 15533(a)7 All roofs shall be inspected prior to any roofing material being'installed.
Q Yes No/
Will the applicant or future b Ids occupant use equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminant' defined by the Bay Arca Air Quality Management all new materials for inspection.
Wrier?
❑Yes
Ihevc read the ba';.
az s materials requirements under Chapter 6.95 of the Califer.
nix Hcohh& elycom, dots S,S5J3 and 15574.1 understand then if the toiheng
does not c ally hese a lana. t it t my marro ihility to no lythe acts ant of the
reyuircmc whie oat dorta'aaanc nracemreatcofoc - IgnatureofApplicant .. Date
n a....... agent Da All roof coverings to be Class "B" or better
CITY OF CUPERTINOO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN#
Building Address: 7 l t
Owner's Name: n Phone#: 67 7!!t}
Contractor�� Phone- � g f C License#:
Contact: \ Phone: / Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project: ^ \
Qty. if
App is bl 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 I Business License BUILDING