03110157 CITY OF CUPERTINO .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO03110157
10191 N BLANEY AV
OWNER'S NAME: PERMIT ISSUE DATE
NALD SINGER 10297 S DE ANZA BLV 11/26/2003
NE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
+00
LICENSED CONTRACTOR
trade,SDECLARATION
£m❑ 1Wrebyaffirmthat IamftheBdunderndProvaofChapter9(commencing Job Description
Z<W with ullfor ondeffecDivision Jaf the Business and Professions GOUC,and myliccae is
n., th Licensee
andefrem. / —j Lmu e L2y9C REPIPE/ WATER SERVICE/WATER HEATER
j Littnu CIazCI'S LA ATION
F p Dam l¢ niraz r a%"7 '1 �'s� w �a®tea
f�a ad rt M ,pais ICFcas ISlicrccords ���C■AL®®
)yU _
LLL s$d P pfessional
ms G OWNERS(1 ER CLp ATION JAN 2 6 2004
<S 1 hereby affirm that I am eae fru a CO., Lieenx Lew for the
00 following reason.(Section 703 1.5,Business and Profcs.ions Code:Any city or county
S$ which requires a permit to concoct,alter,improve,demolish.or repair any nruatum O 0 0
primmits isstuince.il.im,,imstheapplieam for such permit to file a signed statement
£ < that he is licensed pursuantmmepmvisionsnnheComvemr'sLicense Law(Chapter 9 Sq. Ft. Floor Area
trta (commencing with Section 7030)of Division J of the B usiness and Professions Cotte)or
i $
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for s permit subjects the applicant Io a civil Penalty of
not mom man five hundred doll...IS3007. el Occupancy Type
❑ 1,as owner of the progeny,or my employee.with wages as their sole campensadmi.
will do the work,and the suuctua is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves untocon,and who docs such work himself or through his
awn employees,provided that such improvements arc not intended oroRered for sale.IL
however,the building or improvement is said within one year of completion,the owner-
Wildef will have the burden of proving chat he did nal Wild or improse fur pure.of
sale.).
I,as owner of the pfopcny,am exclusively contracting with licensed contractors to
cnnswcl the projen(Sec.7064,Business and Professions Cade:)The Cotnnetor's Li-
cense law does not apply to an owner of property who Wilds or improves thereon,and.
who contracts for such projects with a tuna tor(s)licensed pursuant to the Conuagots
License Law.
EI I an exempt under See. ,B&P C for this reason
Owns, Dam
77MWORKER'S COMPENSATION DECLARATION
1 hereby a0irm under penalty of perjury ane of the following deelantimee
have and will maintain a Cenl rrcam of Consent to self-insure for worker's Compete
a provided for by Section 37M of the LaWr Code,for the pedo...of che
k for which this permit is issued.
have and will maintain Wmker's Compensation Insurance,a required by Section
or Ne Labor Code,for Ne performance of Ne work for which this pemrit is issued.
Work��eJ—J-�s.))��ComyPensatinn In once/carrierand Policy numherartier:�l.'Vl,1 e �`X\ Policy No.: �' • L�%�LI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ono section need not be completed if the Permit is for one hundred dollars(Sip))
less.)
1 eenify that in the perromunce of the work for which this Permit is issued.1 shall not
employ any Person in any manner so as In become subject a the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,alter making this Cenificae,or Extra prion,you should
become subject to the Worker's Compensation previsions of the LaMIr Code,you must
JQ fardwoh comply with such ioswsiaa or this permit anal[W m
decnd remked.
Z� CONSTRUCTION LENDING AGENCY
1 hesohy affirm Nat there is a comuuction lending agency for the Performance or
5 the work fur which this Permit is issued(Sec.3097,Civ,C.)
LOQ Lender's Name
Z Lender's Address
U 0 1 certify that I ban read this application and sum Out the above infmmatiun is
1L P comic.I agree In.comply with all city and county orule.,.and sum laws relating m
Wilding concoction.and hereby autmse
ire mpfcnratiru or this city to enter upon the
V
U she,.mentioned property for inspersion porous.
U Z
(we)agree to save,indemnify and kI,, harmless to City of Cupertino against VI
h liubilities,judgmen :cosuan xpcnu hick ay in anyw.,s,,tic against said City
(„) z APPLI consequence egranl' goo this rmit.
APPLICA DERS NDS DW MPLY WITH ALL NON-POINT Issued by: Date
SOUR U TI
�w Re-roofs
ign YApplicanuConuanor Data
HAZARDOUS M/T ISCLOSURE te Type of Roof
Will the applicant m(.Luft bt(ilding occupant atom or handle hmarduus material
deGocd by the C.perhom Mu mlpal Code.Chapter 9.12,and the Health and Safety
ode,Section 25532(a)?
pees No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant 4r future building occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hrrard us air contaminams as defingl by Be Bay Area Air Quality Management all new materials for inspection.
evict?
❑yes /+7TNu
I have read tl¢WvYNrms rialsm ire m,%undcf Chapter&95ofthc Califor
is Hatch "Safe C Sce. 5505, d2553d.1 understand thmif the building
data not vire no a Iii m
an W is apo dity w only the occupant of the
mquim enk Up" 6 indicate fOccupancy.
f .� Signature of Applicant Date
r feamnrimdagent DateAll roof coverings to be Class"B"or better
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE v 3 % ( ° /S/
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
i oco
Building Address:
D N. 81ryjd ►eve
Owner's Name: I Phone #:
EbnM S YI �r �
Contractor: Phone: License #:
v 2�F53CCp (S 90�
Contact: — Phone: Cupertipo Bess License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Cx:700eg (-1)e -6 0 w
� �t-er SjzvLo "�er ��?I-a✓�
pRes,defnpt,ial `FSU Commercial ❑
roject:
Qty. if
AtWli4ble Fee ID Fee Description Fee Group
PPERMITFEE mbin 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
B SLIC Business License BUILDING