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04010112 • CITY OF CUPERTINOF -n ATIONPERMIT XN14T4BUILDING DIVISION , • BUILDING ADDRESS: - PERMIT N004010112 OWNER'S NAME: PERMIT ESUE DATE E: SANITARY NO. - CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH 0 0 0 0 �Oo LICENSED CONTRACT'OR'S DECLARATION Job Description up 1 hereby 4MI.that 1 em licensed under provisions of Chapter 9(commencing p �W with Section 7")of Division 3 of NC Business and Profession Code.and my license is awn Li 1. a. l�Pj REPLACE SEWERS C C n_ License Class -. LM.N ■ I N.A LE� Data cmmreaor CONTRACTOR: BEYONG PLUMBING qq ARCHITECTS DECLARATION— ndemu 7 an 11 he li rector den � J JAN 2 6 2004 3Wot;; Licearind lindessudmil g OWNER-BUILDER DECLARATION �sk <f 1 hereby of ern that 1 am exempt Ind.the Contractors License Law for the _ B�'rol'SIM o O following mason.(Section 7031.5.Business and Pmfcxsiuns Code:Any city or county 4. which requires a Permit to construct,alter,improve,demolish,or repair any structure yZY prior to its issuance.also requires the applicant for such Permit to File a signed statement g that he is licensedpunu.nttothepmvistonsOftheContractor'sLicenr<taw(Chapter9 Sq. Ft. Floor Area Valuat rgg00 y $ (commencing with Section 7")of Division 3 or the Business and Professions Code)or Out tw is exempt Nemfrom and the Ensu for the alleged exemption.Any violation of Section 7071.5 by any applicant for a permit subjects the applicant to a civil pcoslty of APN Number Occupancy e not more than five hundred dollars(5500). P Y `7 P ❑1,as owner of the Property,or my employees with wages u their sole compensation. 35619018 . 00 will do the work,and the structure is not intended ormffered fonsalo(Sec.7044,Business end Professions Code:The Comments's License Law does not apply to an owner of Required Inspections property who builds or Improves thereon,and who does such work himself or thmugh his own employees,provided that such improvements ve not intended or offered for sale.If. however the building or improvement Is sold within one year of completion.the owner. builder will hams Ne burden of proving Nat he did not build or improve for purpom of sale.). ❑1,as owner of the property,am exclusively contracting with licensed mntr,pan to construct the pmjecl(Sec.7044.Business and Professions Code:)The Contractor's U. cense law dao not apply to an owner of property who builds or improves Ihereon.and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I not exempt under Sec. ,B J,P C far this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby M.node,porosity of perjury oro of On following declarations: have and will maintain a CcAficate of Consent sel6insure for Workers ComPen- anion,nprovided far by Section 7700 of the labor Code,for the peRormance of the . work for which this permit is issued. - ❑I have and will maintain Worker's Compensation Insurance,as required by Section 1700 of the Labor Coda,(or the performance of the work for which this permit is issued. . My Worker's Cam nation In urence carrier and Policy numberam: Co.er:.'�4-A � sJN� Policy No.:l762.i(n0 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed Edic remit is formic hundred dollars(51o1B or less.) I Certify Not in one Performance of the work for which this permit is named.I shall not employ any person in any manner an as m become subject o the Workcri Compensation Laws of California.Dem Applicant NOTICE TO APPLICANT:If,after making this Conifmam of Exemption,you should become subject m the Worker's Compensation provisions of the Labor Code,you must Q O forthwith comply with such provisions ter this Permit snail be dimmed rcvnked. „'Z.t 7 CONSTRUCTION LENDING AGENCY - .�. Ihereh affirm that there is a construction lending acne for Ne F Y 8 s Y Performance or Ri ti the work fur which this permit is issuctl(See.Jf97,Civ.CJ MA Lender's Name � z Lender's Address U Q 1 eerily that 1 have read this application and stem that the above information is l2. (~ cored.l agree to comply with all city and county ordinances and smfe laws relating to 0 building construction,and hereby saturnine representatives of this city in enter upon the �U abova-mentioned Property ter inspection purposes. (We)agree m save,indemnify and keep harmless the City of Cupertino against tF 4 liabilities,judgments,costs and expenses which may in any way see=against said City V Z in consequence of the granting of this Permit. ? ^i APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date3 J ^ S ERE rAt)IS _ _10 Re-roofs ignamrc of PPIinHAZARDOUS MATERIALS DISCLOSURE Data Type of Roof Will the applicant or future building occupant store or handle ha�ous material as defined by the Cupertino Municipal,Code.Chapter 9.12.and the Health and Safety Code,Sununu 25572(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes * Will the applicant or future bonding mccupart use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove Ina stands air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. - uit, ? ❑Yes 1+�tJm I have read the hazardous materials zaaterials requirements under ChaPrer 6.95 of the Califon nia Health1,Safety Cock,Sccuen 25505.25533 and 25534.1 imucmmnd dim dole Inadding .. does not cimandy have a mtnnt that it is my rcspars Alit,to notify the rccuPant of be mqulmmcnls wnidy�ua be met PA.,in sauance of a eenincate or Occupancy. - Signature of Applicant Date . 11 (a - i3 -O owner rr au n rirctl stem Data All roof coverings to be Class "B" or better CITY OF CUPERTINO „ � v Jull2_ REPIPE/SEWERS/MAIN SERVICE CUPEkTiNO PERMIT APPLICATION FORM APN# © Date: 6 Building Address: k ' / C U C;e 7 Owner's Name: Phone#: 7-45,e a- S 0�-j C c� Contractor: Phone: 5—/ 0 License#: ,cJ U/Y1 it/ O S S/D FSO/ Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg Elect ❑ Plum Job Description: �q Residential ❑ Cbmmercial ❑ Cost of Project a Qty. if A li 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 Sewa a Dis osal PLUMBING BUSLIC Business License BUILDING 2 7 zl 7• �6