04100003 . III PPERMIT'
ERTINO. .- - :i�''-• ' �"" ,'
C�1V�RACTQRIkpRM1xN37
BUILDING DIVISION - c
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aILDINGADDRESS: ': PERMITNO.
04100003
R7171 PPNT`1RRQA2T PITT,
-OWNER'S NAME: - PERMIT ISSUE DAM
ONE: -""" - SANITARY Q&tOL NO.
ARCHITEC(ENGINEER: + r BUILDING PERMITINFO ..
BLDG ELECT PLUMB MECH
0 0 0 0
u O o LICENSED CONTRACTOR'S DECLARATION .. r
u 1 beery affirm that I am htcnsid under previsions of Chapter 9(commencing _ - 70b DeSCrlI t,on -- -
with Section 7")ofDivia 3 of dee Business and Prefcssiom Code,and my Hecnu is
_ In
full fano and clfen --
,q= LkennClw Lm x WAT R TR1 IyN LOCATION)
L Dam Cun DECLARATION r
9�
ARCH.h.:1h ate DECLARATION _. ... .....
1 understand my plans shall heated u Public records 4SCu ('
3 Gu,t; Licensed Prof.cuoml ^' - R-j-, 10
H5:0.1
00S -
OWNER-BUILDER DECLARATION
1 hereby affirm Nat 1 am exempt from use Comnnors License Law for the
,22 following leoon.(Section 70315,Businessand'Profcomns Codc:Acycityercounty 8
which leq.1.a permit us construct,alter improve.tamales,or leput,any stentme -
yZY prior as is,issuance.also mquiresthe applicant for such Permit tofile asigned statesmen. ry, Value n
'p that he is llcamed pursuant to the provteio9s of the Connector's License Law(Chapter 9 (1'. Qpr(rA[Casp .. . ..
y�$ (commencing with Section 70110)of Division 3 of tie Business and Professions Code)or
that hes exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a one.penalty of 3 perp p - Occupancy Type
not more Nan five handled dollars($500).
wi I,o eor work. rad prestruct re is omployeea withwagesas Nei(sole 044,8 ones;
will de lenand the structure is ten's Licensetanded offered do es not apply In an owner
Required Inspections
sod Professions Code The Contractor's License Law docs net apply lf an owner of q - --- -• - -'
Ownpropertymploy b,provirimped es daemon,suchimprovndwho daeasucbended omnlfer through We his - ..
however.
Provided thiovemimps sold wiBaune year fumplReud for owner-
'budder.Ne 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
ialcJ. '
1,as owner of the property,am exclusively contracting with licensed contractors 1.
street the project(Sec.7014,Business and Professions Cade:)The Comrutor's Li- _
conn law does not apply to m owner orpropedy who builds ar improves deeeon.and.
who contracts,for suchrceeu wit a conwemr(s)licensed pursuant to Ne Cenentor's ....., .: -..-.
p l ,. . -
ense
❑I am crump,under See. B&PCfer this n ..
Own yC�r!
WORKER'S COMPENSATION DECUCIPION
I hereby affirm under penalty of perjury,ane of the following declarations:
�+ I have and will maintain a Cutificam of Consent to olf-insole for Work.e.Compcn. -
station,as provided for by Section 37110 of the labor Code,for the performance of the
work for which Nis permit is issued,
❑I have and will maintain Worker's Compensation Insurance,as required by Section - -
3700of the Labor Code,for the perfmmancc of the work for which Nis permit is issued. -
My Workoes Ccula naalion Imuname carrier end Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
Into section need nmbecempicted Hire permitisforcre hundred dollen($100)
or less.) .. _-,-..z --
I Mmly that in the Performance of the work for which this permit Is issued,I shall not
empioy uy person in any tarter.as an become sebj.cuo Ne Workers'Cempenotion -
Laws of Ca.mrnla.Data
Applicant ..
NOTICE TO APPLICANT,If.after reeking this Centficme of Exemption,you should
became subject a Ne Worker's Compensation previsions of the Labor Code,you must
.JO forthwith comply wide such provisions or this Permit hall be domed ranked.
'Z' CONSTRUCTION LENDING AGENCY
[•+4 I hereby affirm Nat there is a construction lending agency for the performance of
FL> Nc work for which this permit is issued(Sec.3097.Civ.C.)
Q tanticfs Name
Q z Lender's Address
U Q I unify Nat I have read this application and state that the above tnfmtmeme is
IYr F correct.I agree to comply with all city and county ordinances and state laws elating to
0 building contraction,and hereby amorim eprcunNtives of this city to enter upon the
N W above-mendoncd property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tifn liabilities,judgments,costs and expense,which may in any way we=against said City
fJ'z, in consequence of the goading of this permit. (,
r"+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PONT Issued by: D '
S RC EGULATIONS.. ---y,� _
�L/,(/.,,T/�/�lL.y /oj 170/0 Re-roofs
5ignal"ima�f ppli� lmmor - f OIL.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stere or handle hazardous material
ss defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
oda S alien z5532(aYr All roofs shall be inspected prior to any roofing material being installed.
❑Ycs Iva - ..
Will the aPPlicam or luras building occupant use equipment of devices which- -,If aroof is installed without first obtaining an inspection,I agree to remove! . : a
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ve /
1-7 yea, V NO
I have eW the hmarNws materials requirements undcrChapue 6.95 of the Calfor-
ia H..IN&Safety Code,stern.25505.25533 and 25534.1 amounted Nm if de building
net currently haa tenant thea it is my espo ihnility to mfy Ne occupant of the aimm,at,whim mus be at priorwissu�oft Cc ry'owe of Occupancy. Signature of Applicant ^ Date
`'tom 6 / 0 All roof coverings to be Class"B"or better
honaad agent Dat -
Community Development
10300 Torre Avenue
' `Y,! ` ✓' Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
UPERTINO.
Building Department
JOB ADDRESS: PERMIT #
/V '7/ PeAd e,, r o oo 3
OWNER'S NAME: 4-p- t PHONE # 3 a
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
Owner r Signature Date
CITY OF CUPERTINO
WATER HEATER 6
CUPEKIINO PERMIT APPLICATION FORM
APN# 37S �7� 03s D t�
Building Address:
¢77 lBncltr
Owner's Name: Phone#:
lv . 1/051- 3Y3 - o7oa
Contractor: t License#:
Contact: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ /Plumb ElMech El
Job Description: -stv,// TaAIalev.S X1,7 ive ,r/�ee�, Ot4o f�ocwlio�
Residential P Commercial ❑
Cost of Project:
Strapped On latform Bonded
• New Location Re lacement
f1/. if
c le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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