04030240 CITY OF CUPERTINO *' " ^��'"' �"' "'
BUILDING DIVISION PERMIT CONTRACTOR4INFORMATION
BUILDING ADDRESS:ICKET -1411-T- RP
PERMIT N0.
DAHL PLUMBING CO, JOHN F 04030240
OWNER'S NAME: PERMIT ISSUE DATE
WTTJ,A CAMPERLI, 22 9- - Al MA PT
HE SANITARY QAtOL NO.
J
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Loo LICENSED CONTRACTOR'S DECLARATION Job Descriptio
m 1 hereby affirm that 1 am lieco ed under provisions of Chapter 9(commencing �k q
it wim Sc Uon7MKYOf D" 'si n 3ofdm BusinessSNdyrofeuiuro Code.and myliccvcu
^�N in full fo �Jy
5qg Licen,� coniranr. CONDENSOR (36000 BTU)
W te ARCHITECTS DECLAR N APR 23 2004
7 I understand no,plans shell M used as sibliceficecums
u V Licmved Professional
s'O OWNER-BUILDER DECLARATION BUILDING
1 hereby affirm Nat I am exempt from tier Conuecsor's License Law for she
G0 following mosnn.(Sccuun 7131.5.Business and Professions Code:Any city or county
x m which mquires a permit m cmrwct,eltor,improve,demolish,ser repair any momhou
m—m prior to is issuance.also sequins the applicant for such permit w file a signed statement
t?< that be a licensed p...Ot1.Simprovision at the Committees license LawChapter9 Sq.Ft. Floor Area ValuaA
zit-$ fecannum ingwith Savon7B )o(Div ion3ofthe Busincssand Professima Cm )or
�' that im,is exempt therefrom and the bssis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicanmo a civil penalty of 3 4VN_"Ig*er0 0 Occupancy Type
not mon than five hundred dollen($50)).
❑I,"own"of the Property.or my employer with wages as their able compnaadon,
will do the work and the structure is not intended or offered for We(Sec.7W,Bualnm
and NofcssHtts Code:The Curnsom es License taw don not apply in an owner of Required Inspections
propcny who builds m i reproves Hereon,ane who doessuch work himsel f or tMugh his
own employees,provided Out such improvements art oat intended oroRosed farwle.If.
however,He building or impornment is Sold within one year of completion.He owner.
builder will have He burden of proving that he did not build or improve for pugroae of
ant.).
❑1,u owner of the propeny,am axclusively contracting with licensed cumuacmra m
cumsroct the pmiea(Sec.7(34,4,Business and Profession Cade:)The Conuacmts Li-
ne law does not apply in an owner of Similarly who Wilds or improv"Herron,and
who contracts for such pro acts with a conlnemr(s)licenmd pursumt to the Contractor's
License law.
0 1 ser oxcmpt under Sec .B k IeC far this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declantians:
I have
and will maintain a Cenifwte of Consent to self-insure for Worker's Comfort.
sauon,ss provided for by S"tion 3700 of He labor Code,for He pedo...of He
work for which this permit is issued.
I have and roil maintain Wortrta Compensation insurance,es nquimd by Section
1700 ofN Labor oM,f Rlithe peRormanec of He woh far w�hirc�phz¢H.;iysµpet�mit itis ad. q�
My Wit
Cam at"1 Inwrvtce carrier a d Policy numbe4
ani : C1g cy No.:
CERTIFICATE OF UEISSIPTION FROM WORKERS'
COMPENSATION INSURANCE
(TIs Section need not W completed if the Permit is for one hundreddollars(SIM)
or lass.)
I ecNfy that in the performance of me wart for which this Permit is issued,I shall not
employ any peon in my marmot ab as to become subject to the Workers''Compctnation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to the Workef s Compensation this provision of the resd Labor Code,you mon /a
.J{Z foMwim comply with such pmvisinn or His permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
l hereby affirm that Hen its construction lending agenry,lm the performemx or
<>: He work fur which this permit is issued(Sec.3097,Civ.C.)
27 Lender's Name
a. Lender's Address
U0 I coldly that 1 have send His application and sum than me above information is
UL F comem I agree to comply with all City and county thromboses and gam laws relating in
0 building construction.and hereby aumorirs mpresenathms of this city to inner upon Ilio
W alwve-mentioned progeny for impecuon purposes.
(We)agree to save.undinuffy^keep homeless the city of Cupertino against
tiV1 liabilities,judgments,costs"it es s ich may in any way¢at�c against said City
U Z in cotnegwnee of ine,senting a( a perm .
^' APPLICANT UNDERSTANDS ND W OMPLY WITH LL N -POINT Issued by: Dat
SOU CE itTIONS.
�5LL.
Re-roofs
i azure of App t an✓Conuamor - Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future Wilding nec tint store orhandle huardous material
as,defined by He Cupertino Monte Code.Chapter 9.12.and me,Health and Safety
code.S"ualin un 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or ming occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Iron hazardous air mmuminse fined by she Bay Area Air Quality Management all new materials for inspection.
Dinrim?
0Yes Nu
Ihavc maJ me ha.ardnus mated¢ aqui menuunderChapter6.95ormcCalifor-
niaHwlm&Safely Code.Sections 25N1 25573 d2 1,4.I undcntmd HnirHc Wilding
Jars not rtcntly hoc a Icnam,mat it a my r sp iM1ility m motif y tW mcupant film
¢qui m hichmnIbe poor um c IcauhwteofOccupancy Signature of Applicant Date
AAA )aneraramhat;.<dagent � )m All roof coverings to be Class"B"or better
• Community Development
S" a
10300 Torre Avenue
it Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRES : PERMIT # `j c`t
ZZ ` O `"
OWNER'S NAME. 46/pPHONE #1(U l� 3 (�
GENERAL CONTRACTOR:{: Q \ 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
,
Contractor Signature Date
CITY OF CUPERTINO
Dq p 2 021 o
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date:
3tia - 35 - L kG
Building Address:
aik6'A 0 �z — 4� k(n
Owner's Name: Phone#:
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ El b ❑ Mech
Job Description:
Residential 11�1-- ommereial ❑
Cost of Pro, t:
Strapped On Platform El Bonded ❑
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLI Business ice a BUILD G
09