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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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CONTRACThR TNFURMATION 4.'
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6UILDING ADDRESS:
1725 COLT-TNGSWORTH ST
DIJOSEPH' S PLUMBING
Pumm"903100151
OWNER'S NAME:
205 WYANDOTTE DR
PERMIT ISSUE DATE
MUHLSTEIN LADO JR AND RLEAN
R
10/21/2003
ONE:
(408) 365-2058
SANITARY NO. CONTROL NO.
ARCHITECTGINEER:
BUILDING PERMIT INFO
BO ELECT PLUMB MOECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Descri tion
P
1 hereby affirm that I am licensed under provisions of (commencing
with Section 7gg) of Division 3 of Ne Business and Professions Code. and my licema is
if
COPPER REPIPE
LeneClamenssdcffe,fc,P� %GY ue,a �' 6'
Glu.
9�
Date
Dale CamrECL
Q
ARC DECLARATION
1 andCRldnd my plans shall ho nod as pY111iC mCnrd!
all ho n
Licensed Pro essiona
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following mason. (Section 7031.5, Business and Pro(canions Code: Any city or county
which requires a permit to construct. RISS, impmw, demolish, or repair any structure
$6650
prior In im issuance, also requires he applicant for such permit to file a signed statement
that he is Bemaed pursuant to the provisions of dao Common's uceom Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7o W) of Division 3 of the Business and Pru(examns Code) or
35617066.00
met W u exempt therefrom and the bssu for me alleged exemption, Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty Of
not more than five hundred dollars (SSW).
❑ 1, as owner of the property, or my employees with wages as Limit ole compensation.
Required Inspections
wall do the work and the structure is not intended or offend for We (Snc. 70N, Business
and Profession Code: The Conlnaor's License Law does not apply to an owner of
property who builds or improves thereon. and who does such work himself or through his
Own employees, provided that such improvements ora not intended of offered for tile. If,
however, me building or improvement is sold within one year of completion. the net.
builder will Rave he burden of proving Thal he did not build or improve for purpose of
sale.),
1, 0s owner of me property. am exclusively comRCling with licensed conVRCbR to
construct the pmjecl (Sec. 70x4, Business and Professions Code:) The Contractor's Li.
come Law docs not apply In an owner of property who Wilda or improves daemon, and,
who Contracts for such projects with a coolRCtor(s) Imemsed pursuant to the Contractors
Lkenes Law.
I am exempt under Sec. . B k P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under Penalty of perjury one of tine following declarallons:
I have and will maintain a Cenificata of Consent selNnsum for WorkcraComport-
..tion, as provided for by Section 37M of the labor Code, for me performance of the
work for which this permit is issued.
❑ I hove and will maintain Workers Compensation Insurance, u required by Section
3700 of Nc laWrCode.forlW performmce of dS woh for which Nis permit is issued.
My Workers Com�(nsetio�n+lnsunn�m/canior and Policy number am:
� LhN
v�37gp
C',Y . I' PolicyNo.: �2-/-02"/'11
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seedon need ownummplemd if the pttmit Is for one hundred dollars (SIM)
or loss.)
1 ccr iry dual. In the performance of me work for which this Permit is issued. l shall not
employ any person in any manner an an to become subject to IN Worker Compensation
Law. or California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Ccnificsm of Exemption, you should
become subject to the workers Compensation provisions of the labor Code, you most
forthwith comply with such provisions nr this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mel there its construction lending agency for IW Performance of
me work or which thin permit a issued (See. 3097, Ci, C.)
Lenders Name
Lender's Address
1 certify that I have read this application and min that the above information is
COMCI. I agree to Comply with all city and County ordinances and role lam mlating In
building construction, Rod heroby aulhmim Spmwmatives of thin city to emer upon the
ahovcmemioned properly for impccdon Purpeses
(We) agree to cave, indemnify and keep harmless the City of Cupertino against
Iiabilides,judgmem, toadstool expenses which may In any way accrue amot to City
in consequence of the granting of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR ERE ULAMONS r
Re -roofs
w AA,'k�4 /06r?I +?i
Signare vof ApplicanVCon� Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant awe or Randle hvudous material
as defined by the Cupertino Municipal Codc, Chapter 9.I2, and the Health and Safety
ode. Section 25532(a)7
Yes
❑j�A'u
All roofs shall be inspected prior to any roofing material being installed.
' If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or mlare wading Occupant esu equipment or devices tussah
it wramdous air contaminants as dcOncd by the Bay Area Air Quality Management
all new materials for inspection.
uttict7
❑Yes AQu
Ihave mad the hc. andous requirements under Chapter 6.95 of the
See=255 ,2553ls
nice Health g Safety Code, Secants Wilding
2553a.l nd does ifft,.N Wilding
ou it i my rend
does not cuncndy have a u:nanl, Nel It u my responsibility, m nobly 0S oecupant of the
OR emi
.quirOmpts whist must is,Me gbof. C.mfc.cof occupancy
�67
Signature of Applicant Date
(/^tie /
All roof coverings to be Class "B" or better
Owner or authmired agent Dam
•
•
CITY OF CUPERTINO�
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION. FORM
APN# 3-'26
((J — / /Date:
(
Plumbing Permit Issuance
Building Address: ^
2 / ;;�,2
Owner's Name:l,a /� /� L / /
Gl /7 !Phone:
Phone � f 3 ^ 09��
Contractor: �S//,�(
3�fr�D ��
License
Contact: ' P Phone:
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb IK
Pbl . Fixture
Job Description:
t P/t,//'(0
BP.WSVCS
Residential o er 'al ❑
PLUMBING
Cost of Project:
Sewers
Qty. if
mlic2blp Fee ID
Frr t)rcrrintinn
Frr Cwnnn
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
BP.WSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Dis osal
PLUMBING
BUSLIC
Business License
BUILDING
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