04060057 CITY OF CUPERTINO g�' p �y /"� ��f�7ay�Typp ♦:a * 1I��TT
BUILDING DIVISION PERMIT °CONTRAC=C012 Tr1.C� n`YTA�4�a',
BUILDING ADDRESS: DIJOSEPH' S PLUMBING romrNO.04060057
10552 LA RMA DR
OWNER'S NAME: PERMITISSUEDATE
DAVUD BARR 205 WYANDOTTE DR 06/07/2004
ONE: SANITARY NO. CONTROL NO.
(408) 365-2058
ARCHITECrENGiNEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
1w, LICENSED CONTRACTOR'S DECLARATION
u� 1 hereby affirm that 1 are licensed under provisions of Chapter 9(commencing lob Description
a�
with Seen..7")of Divlalon Sof the Basins,and Poofcasiuns Code,end my license is
n in toll fora and effect! / REPIPE
j J, License Clrsa l Lie.p I
p Dam ^ Contractor
e 7W RCHff-CPS DECLARATION a
Y I understand my plans shall he used as public rce.N. -
Licensed Professional /ox
OWNER-BUILDER DECLARATION /)[
<2 1 hereby strum that 1 am exempt from the Contractor's License Law for the
Ca
� following mason.(Section 713 L5,Business and Pmfeuions Code:Any city or county
which requires a permit n)consuun,alter,improve,demolish,lir repair my structure
y prior in its issuance.also mquinu the applicant For such permit An file a signed statement
Exp that he is licensed pucon ent to be provisions of the Conuacmr's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
or 1- (commencing with Section 0008)of Division 3 of the Business and Professions Code)or
that he is exempt themfmm and the baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant,for a permit subjects the applicant te a civil penalty of of O Occupancye
not more than firs hundred dollars(6500I Typ
❑L as owner of the property,m my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sm.7044,Business
and Professions Cade:The Contractor's License Law does not apply Or an owner of Required Inspections
property who buil da or i m praves thereon,and who does such work himsel f or through his
own employees.provided that such improvements are not intended oronered formic.If,
however,the building or improvement is mid within can year of completion.Ne owner.
builder will have the burden of proving Nat he did WI build or Improve for purpose of
sale.).
❑1.as Owner of the property.am exclusively contracting with licensed contractors to
construct the Project(Sec.7044,Business and Professions Code:)The Conuutor's I.I. ,
tens,Law does not apply to an owner of property who build&or improves thereon.and.
who contracts for such pmjec0 with a conuacmr(s)licensed pursuant to the Contractor's
License Law.
❑lamesemplunder Sec. ,BRPCfor0dsneamn
Owner Date
7371MWORKER'S COMPENSATION DECLARATION
1 hemby affmm under penally of perjury one of the following decimations:
1 have and will maintain ACeNBate of Consent to self-Inure for Worker's Compen-
,
on,as provided for by Scotian 37W of the labor Cade.for the performance of the
k for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Schon
Of the labor Code.for the performance of Ne work for which this permit is issued.
Workm's Compenmtion lnserance smite end Polity nwyTtbcr 'prier. �AH1Yj'C A`� Policy Na.:•'� V-�
CERTIFIC 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7 is section need nmbecompimcd ifthe(ermit is for000 hundred delta.(SIM)
lir less)
1 certify that in the perfarmance of the work for which this permit is issued.l shall not
employ any person in my manner so as to hecomm subject to the Workers'Compensation
Law'
of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificare of Exemption,you should
become subject in the Worker's Compensation provisions Of the labor Coca,you most
.J O forthwith comply with such provisions or this permit shall be deemed mvoked.
'z0 CONSTRUCTION LENDING AGENCY
[-t 4 1 hereby alWm dm there is a comtructina Imnding agemy(or the pe,(mmanee of
a 7 the murk for which this permit is issued(Sec.3037,Civ,C.)
ALender's Namc
07. z Lender's Address
fJ O 1 certify that I have mad this application and some that the above information is
Bra P correct.l agree to comply with all city and county ordinances and suite laws relating to '
O V building construction,and hereby authuriae representatives of this city to enter upon the
W above-mentioned p aNny for inspection purposes.
GL (We)agree to rove,indemnify and keep homiest the City of Cupertino against
,r rA liabilities.judgments,costs and expenses which may in my way accrue against said City
in
of the
of
his
V fz" APPLICANTPUNDERSTA'N�D.aSIAND^WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGvy�S(A Nt I i'7^P Y
Re-roofs
Signatureo ApplicanUContrauor IF Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or future building Occupant store orhandle has ndous material
u dcBncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Section 25532(7)? All roofs shall be inspected prior to any roofing material being installed.
it W0❑Yes /QtNu
Wiil the applicant orIffuture building omupam um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1112.air cantamin.ma ss&rued by the Bay Arca Air Quality Management all new materials for inspection.
istricR yC�
❑Yes jJ rvo
I have mad the hvs ecus materials requirements under Chapter 6.95 of the Califor-
nia HealthA,Safety Coda,Sections 25505,25533 and 25534.1 underhand thaz if the building
does not Cmmndy haw a tenant that it Is my respamlNlily 0 notify Are OccUPmt Of the
requi men whichmustbs,�et o�At�uis�sugmccotaCcrdOca¢ofQcu'c� Signature of Applicant Date
f//(AI 71' In'tic QCy^ / C
wnmr Or authmi ad agent Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# �2 f �U Date:
26q - 33 -
Building Address:
ass L�r���r 1,2k
Owner's Name: Phone
^
�
Av/w c'/ 6ari-,- #�,9 � ^6
Contractor: r Phone: +36S License#:
Contact:/Oti�7 ` hone: r�O ( Cupertino Business License #:
l/� f ./fit � ('/SP �! 7 d"
Building Permit Info:
Bldg ❑ Elect ❑ Plumb I
Job Description:
Residential l/ f �e/rcial ❑
Cost of Project:
• (O
. i
1' ble Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING