03050109 CITY OF CUPERTINO
BUILDING DIVISION PERMIT •�..CONTRAiCTOR'I1V) URMA'CIUN•
.,.•.. Fen:.,-... -.frew.i,'.
BUILDING ADDRESS: PERMIT NO.
I ABLE SEPTIC 03050109
1 �7 a_yn nT.rA 7 A P AltV
OWNER'S NAME: 'PERMIT ,,
520 REED ST. ��I'taL 2/2003
1IT W TT T.TAM
NT (408) 377-9990 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3oa
LICENSED CONTRACIOR'SDECLARATION Job Description
1 hmoby affirm.bet 1 am licensed u r vmuas of Chaper 9(commcaing P
�,� WIN pion BBD)of Divhdon3of dm BUSinI d Prefeulnm Code.andmyliccomis
W lml oil eBea�._ 4 Leg tyS EXTEND SEWER LATERAL/INSTALL CLEANOUT
Fp Dam Canuam,
<gl ARCHITECTS RATION
e 6 u nund my plans,4411 Mused lie record,
l
d
Licensed Professional
OWNER-BUILDER DECLARATION
a I borchy.(Bens that 1 am
1. eaempt from dm Connectors e:Any Law for the
5 D o which moan.Permit t 71n L5,Business and Improve,stermil Code:Any my or county
$� which require,a pcnmh In mnsWCl,attend W prow,demnitsh,air repair any atnemm
SgC
me,mlm ssuen C.a u.apdres Naappliunt(.,such penmlm Bleeagaedeumm tit
< dW he is licensed pursuant m the provisions of the Commctura Location Law(Chapmr9 Sq.Ft. Floor Area N�Ig�l00
EG $ (commencing with Section 7000)of Division 3 of the Business and Professions Coke)or v
r, dual h I.exempt therefrom and the basis for the alleged exemption.Any vialaten of �}/a.qy�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty a. 3 SIB.tl1"hikt 00 Occupancy Type
not more Nan five hundred dollars(5500).
❑1,u owner of the property,or my employer with wages an their ants compensation,
will du the work and the avucmra 6 not intended or offered forsaN(Sec.7044.Bminw 106 – SEWER R I� sections
and Prolamin Code:The Committee Lt.Law dam not apply m an owner of
pmpenywho Wtldsor barrows thereon,andwho dmsiuch wart hlmsellorNmugh his 202 – UNDERFLOOR PLUMBING
more employes,provided lha.such Improvements are not intended maffcmd for$Me.If, ,301 ROLIGII PLUMBING
however,the building or improwmcnt iaaold within ore year of completes,the owner. .+;-w-� 0.
ykder will low the When of proving that be did na.Wild a Improve for pumom of 509 – FINAL PLUMBING,-,�
El 1,as owner of the property,am exclusively contrucung with licensed commcten an --
construct the project(Sec.7tka,Business and profemium Code:)The Correctors U.
cenxe Law dots not apply to an owner of property who Wilda or improws thereon,and
who contracts for such project,with aeonuaetoKU licensed punwm m the Conuamor's
License Law.
❑larm exempt under Sec. ,B&PCfor this mown
Owner Data - �
WORKERS COMPENSATION DECLARATION 1
1 hereby saw under penally of perjury one of the following dedmatiuns:
I have and will malnWn•CertlOcate ofConsem is self-imure for Workers Compen.
sa.ion.as provided for by Section 3700 of die Labor Cade.fm the yerformaucc of thc
work for which this permit is issued.
❑1 haw adds will maintain Worker's Compensation Insurance,as required by section
3700 of the Labor Code.for de perfarmerme of de work rwhtch Nuperentisissued.
My Workers CompensaWnlostae•� cirand li numbe,am:
me .�-fole ralnr�POU .: I.S.S(J 57
CER11FICAM—OP EXEMrnON FROM WORKERS'
COMPENSATION INSURANCE
('flits oecit.need net be completed time perms.ufor.Wndreddellua(SIM)
m Isla.)
1 certify that in the perfn.mance of thc work for which this permu u issued,l shall not
employ any person In any m sener an a In become subject to the Worker'Compensation
Laws of Califomia.Da•-
Appliesnl
NOTICE TO APPLICANT:If.after making this CCrtlfnsle of Exemption,you should
become subject N the Werker t,Compensation previsions of IN Labor Code,you must
., 0 forthwith comply with such provision or Nn permit shall be deemed revised.
'y = CONSTRUCTION LENDING AGENCY
[-i I hereby affirm that there is a conadmminn lending agency for the porformunic of
lY 7
the work for which this permit Is Issued(Sec.3(197,Cm C.1
W 0 Lender's Nam-
,z Lender's Address
U Q 1 certify that 1 have mad this application and state that the above infosnedun is
LL Fcorrect.I agree to comply with all city and county ordinances and sum laws mlating to
Wilding construction,and hereby authonm representatives of Nn city to enter upon the
show-mcntiomd property for inspection pugiares
0. (We)agree to save,indemnify and keep hamless de City of Cupertino against `
fA Iisbilides,judgmenu,costs and expenses which may In any way acme against aid City
U Z In consequence of NC granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 RCE REGULATIONS. � -- ''PP _Q I
/ TA.e ) I s G✓ 7' \fi4ll 3 Re-roofs
`, Signature of Applican ommocur ,� D� aT
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will die applicant or fuuse Wilding recupant some m handle Imminent material
as ciefnad by the CupenKrO.Nm"building eal Code,Chapter 9.13,and the Health and Safety
bo`•SeNOn 15532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Will the applied occupant u s e equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II havurnim s air contaminants as defend by the Bay Area Air Quality Management all new materials for inspection.
191,IC17 /�^
❑Yes
III ve mat the haallousmamrials requirements under�hmw6,35 f the Carter.
nia Hca lth&Safely Ca ,Sec6om25505.35533re 25534.1 cathe Wild,.,
dace ot currently haw a an ome Nat n u my neepomlhtlny m upanl of thc'Huoee"` wIchmombe metpriormissuanceoflCcmOcy. Signature of Applicant Date
�As e I —x, CY J Z. ZZIO `2,
`- tier
romanticized egoal 6sm All roof coverings to be Class °B°or better
1 CITY OF CUPERTINO
C P. REPIPE/SEDERS/MA➢N SERVICE c S I
�ITY ICUPERNO M PERMIT APPLICATION FORM
APN# ./�-I �j �� Date:
�"/ / Ivl�,�, 2 2,
Building Address: / I
Owner's Name: t Phone
NO Y- �y � � l ok rr\ )& ) '?,a7 9g90
Contractor ( r Phone: License #:
L X17475
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Ir-�l 4P Y1 rI 2 rcial ❑
Residentjn Comme ns+41 p<�per�y bye ��eoh, I
Cost of Project: ®�
Qty. if
A li Fee ID Fee Description Fee Group
ERMFEE Bldg. Permit Fees BUILDING
r I PPERMTI'FEE I Plumbing Permit Issuance _ PLUMBING J
BPREPIPE I Revive of Fixtures PLUMBING
BPFLXTURE I Pblg. Fixture PLUMBING
I BPWSVCS - -
Main Water Service _ _ PLUMBING
BPSEWER - - --
I Sewers __
_ PLUMBING J
I BPSEWAGE
Sewage Disposal PLUMBING____
BENERGY I Energv I BUILDING I
BUSLIC I Business License I BUILDING