03050056U
CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
uC0NT�2A.C''I,UR"%1
BUILDING ADDRESS:
PERMITNOO 3 0 5 0 0 5 6
OWNER'S NAME:
"'9713/2003
EGAN LOUISE L
ONE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
1 hereby afOrm dui 1 w limned under Provisions; of Chaptsr 9 (commencing
with Sacl'rrraaaPPp 7000) ofD"hian 3 of to Buss Professions Cade. and my license is
toullran of" (QL Q
REPIPE/WATER HEATER
License CI LR.
p�
'BALED
ARCHTIECI'SD TID
CONTRACTOR: HYDRO MECHANIC L
un mound my Alam Mall ho used as public meads
OCT 2 8 Z003
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby afrom that 1 am exempt from the Conlrutora License Law for the
following mason. (Smon 7031.5. Business and Professions Cada: Any City nr county
BUILDING
W
which requires a permit m connrvct, ally, improve, demtdRb, or epdr any Boucle -
prior m its Issmmm, alta raquin, the applicant for such permit m rile a signed statement
Comnemb License Law 9
Sq. Ft. Floor Area
Valuation
Nal he is licensed pursuant m to provisions of Me (Chapter
(commencing with Section 7000) M Division 3 of the Business and Professions Code) or
4 O O 0
dm he Is e s mpl rhemfrom and the basis fm the alleged mampdon. Any viola em of
APN Number
Occupancy Type
Section 7031.5 by cry applicant for a permit subjects the applicant to a civil penalty of
nal more than five hundred dollars ($500).
36923030.00
❑ I, a, awns anha property. a my mnployeec with waw.+deir BOW compensation.
Re d Inspections
�^YKTERp
will do the work. and the struMum isnot Needed W ORend fansaR(Sec. 7044, Budrev
Bud Professions Code: The Conumemes License law doe rot apply In an owner of
M1imself duough his
106 - SEWER &
propsny w ho build, m improves thereon, and who dons such work or
wnemplayaa,pmvided thm Mehimprowmantsam mlimarded oroae-A foruk. 11.
'202 — UNDERFLOOR PLUMBING
however, de buildingn, Improvement R sold within aro year of mmpledon, the waer-
builder will have the burden of proving that he did ran build or Improve for purpose of
301 - ROUGH PLUMBING
sale.)'
302 - TUB & OR SHOWER
O 1, as rowel of the popcny, am celusively contracting with licensed contractor, e
construct the pmlact (Sec. 7044, Business and Professions Cade:) The COMMU&, Li-
502 - FINAL PLUMBING ENERGY
veLaw does not apply toancansrofProperty who Wilds orimpromtemon.and ,
506 — GAS TEST
who contracts for such pm)cm with a conuanoKq licensed pursuant m de Cpn1MWs
507 - FINAL PLUMBING
Lipense law.
❑ Iamesemptundm See .BAPCfm MWWaen
R
WORKER'S COMPENSATION DSCLARA�
1 hereby affirm under penalty of perjury one of the following decholt oti:
I have and will maintain aCanfff«e of Consent in elf-Insum fan WorkerBCompen-
elion. a pmvid fa by Section 7700 of de labor Cade. fa the performance of the
work for which this permit i, issued
❑ 1 have and will maintain Worker's Compensation Iruurance, a required by Section
7700 of the Labor Cade. for the parfarmasme of Me work ra which this permit i, issued.
My rkers Compensation Insurance carrier and Policy number am:
«Q Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(Thlssemou need notbecomplowd If the permit Is for one hundeddollan (5100)
an kis)
I «oily that In the of once of the work for which Nis Permit R issued. I Mall not
-
emplayanypenonm mNncrso tab become subject to die Wohcri Compensation
Law of Cabrood aR�
AppliccyylIt� —
NOTIC12 APPLICANT: IL after making this Cer iricae of Eemptbn, you should
become 7 jest m the Worker's Compensation provisions of the Labor Codc. you must
forthwith comply with such provisions or this Permit Mall be deemed revoked.
LEN0INGAGENCY
1 herby affirm that dart is • sending agency for the Performance of
ed (Sm.. 3
the work for which this permit R leered (S«. 7097, Civ. C.)
Name
Lander, Add-,,
I certify that I have read this application and st a that Ne above information is
morel. l agree u comply with all city and county ordinances and BUR law misting e
Wilding construction. and hereby authode rtprtsenuuvas of this City wcnwf upon the
a
above-mansioned pmpcny car Impaction purposes
(We) agree m save, indemnify and keep harmles, the City of Cupertino against
costs and expenses which may In any way ACCme against said City
In consequence of tho granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHL N0N-POINT
Issued by: Date b24
SOURCE REGULATIONS.
Re -roofs
Type of Roof
'ApplicuiXamrlor Dae
a u-oe
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or future building Occupant core or handle 116721IanS malarial
u defined by the Cupertino Mun' 1 Cade. Cluplar 9.11, and the ROOM and Safety
ode, Sm.. 15531(1)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Wier the applicant a future building aavusepnt ucquipmeal se dcvksM which
Il hazardous car conamninanyls defaml by the Bay Area Air Quality Management
all new materials for inspection.
IYV1el1
❑ Yes
I have mal the Meardrw mamri.13 re umunar s under Chapter 6.95 of dm Cables-
niaHealNkSafeiy Code,Secdans15505.15533md15774.1uR ntsndthaiflhc Wlding
dais not currently have• Ra it R my responsibility -notify the a«upenl of Ne
regw ,hkhmu2b pilar inuaRenfaCerifmalaar
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ownerwethoriatda em DaR
�CITY OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/S1ENVERS/MAIN SERVICE
PERMIT APPLICATION FORM
0 3 0 -S- 0 �S^�
APN #
O
Date: /
1XI
Building Address: fG'
Plumbing Permit Issuance
Owner's Name;_,/
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Phone #:
PLUMBING
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Pbl . Fixture
Contractor:
Phone: Y -�2qf-17(FT
License#:
PLUMBING
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Sewers
Contact:
Sfe �-��
Phone:
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Cupertino Business License #:
Building Permit Info:
BENERGY
Energy
Bldg ❑
Elect ❑ Plumb
Business License
Job Description:
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Wqce
Residential—
Commercial ❑
Cost of Project:
Qty. if
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FPP TlPanrintinn
Fee Groun
BPERMFE
Bldg. Permit Fees
BUILDING
W
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
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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