04050090 ;B,WLDINGADDRESS:
ITY OF CUPERTINO .'�' IkNe°F t
BUILDING DIVISION
PER CONTRACTOR INFORMATION
CUPERTINO PLUMBING PERMITN414'050090
NER'S NAME: PERMIT ISSUE DATE
NICK BHA
ONE: SANITARY NO. CONTROL NO.
(408) 253-0618
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
G� 0 L 0'
u00 LICENSED CONTRACTOR'S DECLARATION - Job Description
s u C 1 M.rcby.affirm Wal I am liaracd under pmvisiorss of Chaplcr Y(<ommcnring ^�
G with Secuan lOBU)of Div;sionJofdx Businev end Profession Code.aMm license IF /nl tI SSD
Ncense merf C REPIPE/WATER SERVICE G=y` It �t�
Datense Cl ', N r
�W�
a: my G e JUL 2 f 2004
3 G Lice is �d1pp pp,�a
WNER-BUT ER DECLA ION t pit OLDING
g I both,affirm that 1 am Cat' I form dte Cantracmr's License Law for the Y V
d p O fol wing mann.(Sccuun 7031.5,Boom d ProfcWon Code:Any City or county
K$ w armors a permit to cmmcl.alar,Improve.demolish,or repair any structure snon
FZy pd.,Nie;EYNute.31W toga;nts the apple=,forsuch permit la file a signed statement
F < thehcislicensedpurmanttotheprovisionofthcConnectohLianselaw(ChapterY Sq.Ft. Floor Area Valuation
(commencing with Section 7OXf of Coition 3 of the Business and Professions Code)in
'a $ Nal he is MMPL themf ore and the basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of 3$tFP2QQdxfbe10 0 Occupancy Type
not mom than five hundred dollars(SSW).
❑1.u owner of the proprny,army employees with wage as Ncir sole eompenssdon,
will do the weak end the structure is notinanded oraRcmd fouak(Sas.7044,Busircss
and Professions Cade:The Conmaora Liceme law dos not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees.provided that such improvements an notinwndcd oroffered for sale.Ir,
however,Ne building or improvement is said within one year of completion,the owner.
builder will Wve lh burden of proving dist he did not build of improve for purpose of
sale.).
I.as owner of de,property am uclusively contracting with littmed contractors to
conswct the pmjecl(Sce.7044,Business end Profcs;on Code:)The Conaecmri Li
CO.law docs nor apply,...owner or property who builds or improves thereon,and,
who contracts Ire ouch projects with a contractor(s)licensed pursuant to the Contractors
License taw.
I an Camara undo Sm .B&P C for this moan
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Jas following cledvaliom:
J 1 have and will mdood.aCer ifiam of consent to self-insure fm WmkeriCampm-
ution,as provided for by Section 37M of the labor Code.for the performance of the
work for which this permit is issued.
have and will maintain Workcri Compensation Insurance,in required by Sectio
W of the labor Code.for the performance of the wort for which this permit is issued.
My Worts ore oration mrtrantt artier end Pol;ry n�um�beram:
Caarkr. - Policy No.,� �2(�
CERTIFIC TE OF E" MON MOM WORKERS'
COMPENSATION INSURANCE
(Thissection need hat hpeampleted if the permit is foronc hundred dallers(SI W)
air less.)
I certify on%in the perrommroce of the work for which this permit is issued.1 shall nm
employ any Person in any manner so as in become subject to the Workers'Compemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccmfiate of Exemption,you should
become subjem to We Worm,3 Compcmation previsions of Ne IaWr Code,ym moa
,J z fanewith comply with each prevision or this permit shall be clamed revoked.
zO CONSTRUCTION LENDING AGENCY
�-. 1 hereby affirm Nat Nem,is a Comwction lending agency for the performance of
!Y 7 the work fur which this permit Is issued(Sea 3097,Civ.C.)
WM Lenders Nauru
z lenders Adereu
U 0 1 certify Nat 1 have read this application and nate Net Ne shove infomra;on is
0. coned.I agree Io COur wi pll c;y and county ordinances and sate laws relating to
building Conswction,and m yamhomer ace lives of this city to enter upon Nc
slave-mentioned pIvpe fI i avian p use
(—'C (We)q t vie.in ea keep lea the City of Cupenino :m."
Cr
If.if ,coxa des whit may in any wayaamc agaimtsud City
!�Z inonxCq r< peg mg of lh NO r P Y WITH ALL NON-POINT Issued by: Date V�
SOUR
,Al.
YY�- Re-roots
$i Pp man onmct Data
HAZARDOU A DISCLOSURE Type of Roof
Will on,applicant or future building occupant stow or handle hamdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and be Health and Safety
ode.Sccuun 25532(a)? All no All roofs shall be inspected prior to any roofing material being installed.
Ayes 1
Will do,aMliesnr or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
mit hoaallous air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
p Yes o
I hrvc mW Ne n material qui cntsundcrChapter6.95oftec Califon
his Health s y 2550 53d.lundcmatd lhaliflM Wilding
dao note Y e N ts m nihilisy to notify thea oaupant of Nu
mga;mm' , et mi niBateofOcapanyy.Q� Signature of Applicant Date
o err mnavedesent Dna `1 All roof coverings to be Class"B" or better
a Community Development
i 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�
UPEI�TINO CITY OF Fax(408) 777-3333
Building De artment
JOB ADDR PE # _
OWNER'S N (CSC Pmt PHO 'ZSS g2 S
GENERAL CONTRACTOR• v v FAX # O 253 OCo
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information
60 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 U l
Roofing
Septic Tank
Sheet Metal
Sheet Rocl /
Tile
�/� ContractoSi a e Date
CITY OF CUPERTINO OS�b v
REPIPE/SEWERS/MAIN SERVICE
OF
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address: 2 p
`J 5cJ Cir
Owner's Name- Phone
�
Contractor: hoLicense #:
G ►�d Ambi qne: -z!5-7-2. la ( 44,76 S
Contact: hone Cupertino Business License #:
Building Permit Info: —/
Bldg ❑ Elect ❑ Plumb LN
Job Description:
Residential 21 Commercial ❑
Cost of Project: I r�
Qty. if
Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bid,-. Permit Fees BUILDING j
BPFDCTURE Pblo. Fixture PLUMBING
BPWSVCS Main Water.Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
I
CPO`