05110147 CITY OF CUPERTINOr�+ ,t
BUILDING DIVISION PERMIT CONITR OTIOWM'Q1 �lTI0IV
BUILDING AGGRESS: ABLE SEPTIC PERMIT N0.051101.47
.1371 COT,TJMRITR AV
OWNER'S NAME: PERMIT ISSUE DA78
K & M DEVELOPMENT 520 R
NE: SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHITECf/ENGINEEit: BUILDING PERMINFO
'BLDG 0 PLUMS ME�CH
j o Z LICENSED CONTRACTOR'S DECLARATION
Ini1 F FO Dam1 ionJul 1 am licensed under
kr prvlela oof 9((commenting Job DesCTlp
I
L
�E�
®with Section70(BdDivWon 3afJ0)BusincttaM Raessil Code.eb mylkeentsu
mfullrorcoand efficar. INSTALL SEWER C/O
512
LLk.N �
ees^CAO s
ARCHITECTS ds
I understand my plans hOl he used u public words np /o
a O(n Licensed Profemionel
`+y� OWNER-BUILDE0.m CLIRATION
0 C 1 hereby Maso alRrm on I L eumpt from the Gmhns,Co License law for J0)
y&o which re mason.(Sadat 113LI, shm. and ere,dem m Cale:Any city m aunty LL
d
29 which its i ma•permit s,"las construct,the
alter,improve,demolish.t or repair any stmmuro �a+� - O O
_Zi prior muheiuwuedpurmrequku tis applicant fm schpermil70Ole Law(wtemam
< Ihatheklkenscdpurmam7000)ofDivoiuorthe camrxessandcuelawlsCopm9 Sq.Ft. Floor Area Valuatio-
�E $ (eommencladempa hadan70n0)th Division of J0)Busineuana ProfessionsCode)or
C Sc in k au.5 b therefrom and&e aura it be alte{W esmnpdm Any it pWiun of
sut on]0313 by bo bed dana s(a perch Objects me applkanl70•civil penalty or F Occupancy Type
Out mom Nov Rw hundrtd dailua(3700). '
Q 1.u comer of the property,or my employees with wages as that,0)k compensation,
will do the work and themocume is not intended or offered forsefe(Sec.7044,Business Required Inspections
and ProfeNON Cadclo
Coding The CanuLim"s Li "Law does au e nsl apply m owner of q p
praPany whoinat aoriesporw,am mem.and who doessuch work humsefor&moth his
owe employees,provided that mch improvements and natlnmMed moreand forsele If.
however,eve building aimprowmmt Is mid within one year ofeemple0on.the awnm-
buifder .will have lit income of proving that he did tat Mold or improv for purpose of
sale.).
❑1.as,mune,of the Fogarty.are exclusively canucdng with Bamand comment,m
menstruct the project(Sec.7044.Business anal Professions Cede)The Cmu roues U.
come raw dean not apply 0 an owner of Poverty who build,or impmm down,and
who eonusems for such projects with a amrcmr4)thousand Poraannl to the Camauh
License Law.
❑matt exempt under See ,B Is P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby wirm wider parc penalty of perjury aof the following decimations:
I have and will maintain a CaNOcou of Careens m self-insum for Worker's Compen-
utlun,u provided for OY Section 7700 of Use Labor Com.for&e Performance:of 0e
work for which this permit i,issued.
❑I have and will maintain Waftes Compenudon Inm,atlm,u wood!by Section
7]00of the labor Code,for the perform mom of W weak for which this permit Is lased
My Workda Compensation Insunnca eeamia and Policy num me
Coder. �iTt t+..—`—e+^R ,f Polley Na.: JE
CERTI ICATEOF XEMPr10N FROM WOR ERS'
25
COMPENSATION INSURANCE
(Thissemim need mthccmnpkmd if the permit k foromhundrtddoRan($100)
or less)
1 emery than in the Womsna of the work for which this permit is road,I OWI no _
employ any person in my manner an as u become subject m tit Workerf Compensadon
"0'.1 California.Dau
Applicant
NOTICE TO APPLICANT:If,,her matin{this Certificate of Excerption.you Amid
become subject to the We mem Compensation provisions of the Labor Code,you must
.,O Zforthwith amply with such provisions a this permit All k deemed revoked.
'Z r~�+ CONSTRUCTION LENDING AGENCY
(..m I hereby alRrm mu tem lea anmummn funding agency forepeRmmumca of
C ti 0e werk far which 0ss permit kInmost(Sec.3097,CW.C.)
WM p Len0cr',Name ,
.`O 2 Lenaefa Address
V Q I comity she,1 hew mad this application and sum that the above information k
W .r" corms 4 m um 1me comply with all city and county mJinamra and tcows rtfamil m
O building commuction.and hereby authorise representatives of this city in enter upon ft
(sl show-mentioned property for inspection pmpoma
C (We)agree to cove,indemnify and keep hamlas Je City of Cupertino a niou
Vj liabilities.judgmcnu,cow and aspera which may In my my sans,agalml aid CRY
t.1 Z in consequence of the granting of this permit.
APPLICANT UND ANDS ND W D COMPLY WITH ALL NON-POINT Issued by: Date
souRI� ULATI NS.
FC �28�fJS� Re-roofs
Slgmture of� D
HAZARDO MATERIA SCLOSURE Type of Roof
Will the applicant or future building Occupant smrc or handle hammians material
as deri ed by the Cupertino Municipal Code.Chapter 9.11.and the Health ad Safety
0)k,section 2557x4)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y0) 13 No
Will the applicant or future building ompmt me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
J�� roll hmaMnm air conumleanu u defined by 0e Bay Arte Air Quality Management all new materials for inspection.
D Wct7
❑Yes ON.
I have mad the haavdwsmuuuMmquimmenuwderCNpur6.95of&e COifor-
n4lkalth85alctyCodc,3adatiny,
an 25534.ItmJcmmld&mlfJe building
Jura at c ntlY w a Inc L& es siMlity m nu01'y 0e acupant of Jereq w aRx ped a Ttea0)of Signature of Applicant Date
owner a,.athame agent e� Date. . All roof coverings to be Class'B"or better
Community Development
: 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Buildin ' De artment
JOB ADDRESS: PERMIT #
,V,r 57 Cc�wm r�\)S Ak.Q • o S-•iia Cl
OWNER'S NAME: K VV\ Dr✓ L AQ PHONE #
GENERAL CONTRACTO • -A- kle— C',AVnyk-Coh FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
-� CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
$CUPERTINO PERMIT APPLICATION FORM
APN# 3( ?'ZDL c) Date:l l 2�, _
BuildiAddress:
1 I �20-7 1 COL v atiCc�
Owner's Name: Phone#:
lc 7 3c(O -St Z
Contr�t c ✓ /v� Phcane: $ --�-77-99Q Q License#�
Contac Phone: G1 4 Cupertino Business License#:
Building
Permit Info:
Bldg Elect ❑ Plumb ❑
Job Descript'gn'
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees I BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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