07010008 CITY OF CUPERTINO
nA,�'��-+ +CflAAG'�QR IiRATIflN•
BUILDIidGDIVISION P�1JluVlil
BUILDING ADDRESS: PERMIT NO.
10495 SCENIC BLVD PREST
PERMIT ISSUE DATE
OWNER'S NAME:
GREG RICHMOND 133 B()THELO AVE 01/03/2007
_)NE: SANITARY NO. CONTROL NO.
(408) 21i2-1418
BUILDING PERMIT INFO
ARCHITECTtENGiNEER: BLDG ELECT PLUMB MECH
4 0 p LICENSED CONTRACTOR'S DECLARATION Job Description
e v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z m with Section 7000)of Division 3 of the Business and ProSior�s Co�elan cnsc is SEWER CONNECTION NEW LATERAL
H in full force and effect. /o fJ
? License Class Lic.S i
O Date / -Contractorr n In - I f
3 E^ ARCHITECTS DECLA AT10N —TT
D wU I understand my plans shall be used as public records
a
`u.H Licensed Professional
v OWNER-BUILDER DECLARATION
F I hereby affirm that 1 am exempt from the Contractor's License Law for the
%o O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y which requires a permit to construct,alter•improve•demolish,or repair any structure
_ Prior to its issuance,also requires the applicant for such permit to file a signed statement SFt.Floor Area $10000 Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q 10 0 0 0
t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of �,pN
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of 3 5 7 0 6 0 15 :t�l7' Number Occupancy Type
not more than five hundred dollars(5500).
0 I,as owner of the property or my employees with wages as their sole compensation,
will do the work,and the structure is not intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or imprnves thereon,and who does such work himself or through his
own employers,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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B tit P C for this reason
Owner Date In
WORKER'S COMPENSATION DECLARATION ) £
1 hereby afChrm under penalty of perjury one of the following declarations: n r t
t '.r.
Fq
1 have and will maintain a Certificate of Consent to self-insure for Worker s Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the ) '' 4
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers CompensayonI
nsurance carrier and Policy num gra
Camcr.� lir Z Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.) r t
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date 1
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 must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
(Yy the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
04 Lender's Address
V 0 1 certify that 1 have read this application and state that the above information is
Ll.►•+ correct-I agree to comply with all city and county ordinances and state laws relating to
Q Vbuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for ins ction purposes.
>4 a (We)agree to save,indc mi y and keep harmless the Cit of Cupertino against
�to liabiliti udgmcnis,costs an x nscs which may in any way true against said City
U)z in co q rtes aC the tin is permit.
►^� AP 1C NT UND STA ILL COM A NON-POINT Issued t y: Date
S U NS.
Re-roof;
Sign-atofA on Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
i11 th1532(a)?
plicant or future building occupant store or handle hazardous material
as de byCupertino Munici 1 Code,Chapter 9.12,and the Health and Safety
c«fe Section All roois shall be inspected prior to any roofing material being installed.
p Yes o
Will the applicant or forum building occupant use equipment or devices which If a Too 7 is installed without first obtaining an inspection,I agree to remove
-mit hazardous air contaminants as fined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes u
1 have read the hazardou ate'als requirements under Chapter of the Califor-
nia Health afetyCode,Sectio 25 5.25533 and 25534.1 undcrsmn atif the building
docs n ntly have ren y responsibility to notify of the
reyu'"me ch re t be re t c 'fico Date
Signatu-e of Applicant
o r out V agent Dato All roof coverings to be Class"B"or better
,w Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
''UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: & Z, IVLPHONE # 3q t-3 z 3 Z (.4v 0)
GENERAL CONTRACTOR: s o �u FAX #
14 Gs t 6_Z6 z
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and cont lete the following information:
60 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 P��s �t �1,,,,P,a 3 b 7 40
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile -
Own& tractor Signature Date
CITY OF CU
PERTINO D l 000
8
'aF
REPIPE/SEW .S/MAIN SERVICE
CUPEkTINO PERMIT APPIACATION FORM
APN# Date:
—�b - r� zznd
Building Address:
koLt�S GC �
Owner's Name: Phone#:
Gve� �w� y,0i6 -3`t1-3z3 i
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
--- C w -
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential ` 9a Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC j Business License BUILDING