05050046 CITY OF CUPERTINO
BUILDING DIVISIONPERMITnCONTRAC-�TORIFORMATION
NAl
BUILDING ADDRESS: PERMIT NO.
CUPERTINO PLUMBING 05050046
OWNER'S NAME: PERMU MUE DATE
NE: SANITARY �ftOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
E
uoa LICENSED CONTRACTOR'S DECLARATION
G w I hominy affirm Nn I am littnud under provisions of CMper 9(commencing Job Description
O
with ScNciund.)or few
SarNc ausinev and Prorcuiom code.,namyBcemci, �I� p��
n„ Uoiii.il a anacrr C !07 l — REPIPE�WATER SERVICE 0�V®■
[y�? LiccnseC LICA
a F, Dau C mrenor L t T
AR,HITE SDEC kRAT N
cei I undcrmnJ m plan I d u f 4-
'R.
Licensed Pnafcssion 7131' 2005
` O\ aER-BUILDER DE ARATION
1 hereh IT".Nm I em exempt from d.Contractor's License Law for the
E p O following reason.(Section 70)1.5,Business and Professions Code:Any city or county
K m which mquira a permit to construct,alma,improve,demolish.or repair any at.,tum
y¢i prior In na issuance.also sequira the applicant for such Permit to file a signed statement
s< that be is licensed pudmanuo the Provisions M the Common's lJconec law(Chapur9 Sq. Ft. Floor Area U 1
anzw-
¢r$ (commencing with Seedon 7")of Division 3 or the Business and Profosstans Code)or
_
Out he v exempt thcrfrom and the bazis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 9WV2 M*gr0 0 Occupancy Type
not mom than five hundred dollen(S50%
❑L u due
we&.ase Pm strny m my intended
or
w,ges u sato
(Sete eom.Business
will dothesionsCde: Thenarisnmin.mcd orowrent for sok(Sec.]04a,easiness
ane property
obis Cmc:The contiatan.License law dos or apply lf,n ower are Required Inspections
pmpero who builds orimproves thereon,and woo dessuchworkhimaelrorthrough his
Own cmployca,provided inori Ihm such impmmmw is are not arofintended ortuffemplcu ed for owner,
builder ,,the building or improvement is sold within one year of completion,Nc owe of
builder will baro 0.Mrdrn of proving that be did not Mild or improv for purpose or
ale.).
❑1,as owner of Ne property,am exclusively convening with licensed contncmrs to
construct the project(See.]094,Business and Professions Code:)The Contractors Li.
rue taw docs not apply to an owner of progeny who Milds or improv¢Ihemoe,and.
who concur for such pmjeeta with a eanvacmr(s)licensed pursuant to dr Contractor's
Ldenu taw.
❑1 am eampt under sec. .B h P C for Nu reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hcmby aRnn under penalty of perjury one of Ne following declarations:
1 ham and will maintain a Certifiear of consent to self--insure for Workerscomport-
sation,u provided for by Section 7700 of the Labor Cmc,for the performance or the
work for which this permit is issued.
1 have and will maintain Worker's Compensation inaursncc,u required by Section
1700 oldie labor Con,for dm performance of the work for which this permit is issued.
My Worker's
�,Coompensation Insunne cortin and Poli,number art:
Carrier. <]l Al -Vr'vA Poli,No.: �On� InOCi
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu scOil.r.ca not be camplewd if the permit is farm.hundred dollars(SIM)
or thea')
I cerdfv Na in thc performance of IW work for which this permits issued,l shall not
employ any person in any manner u az in become subject to the Workers Compensation ,
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.If.after making this Certificate or Eacmpion,you should
become subject wthe Worker's Compensation provisions of the L,he Cmc,you min
.J 0 forthwith comply with each provisions m this permit shall W deemm mvnked.
'Z CONSTRUCTION LENDING AGENCY
I hereby affirm that Nor is a construction lending agency for the Performance of
�i
Or work for which this permit is issued(Sec.7099,Civ.C.)
a Q Lender's Name
=z lender's Address
U C) I certify Nat 1 have rod this application and show that the eMve information is
F connect,1 agree in comply with all city and county odinances and show laws relating to
.JU building construction.and hemby authoria repmumaliva of this city to enter upon the
above-mentioncd pmperty for inspection purposes.
Fy (We)agree to ave,indemnify and keep harmless the City of Cupertino against
N liabiliues.judgmenta,came Eexpeau which may in any way aecme,gainsuuO City
in
of on
V?
APPLICANT CUNDERSnOU ArND IL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA O S. / t
Re-roofs
Signmurco Ap n mr— Date
n RDOUS M DISCLOSURE Type of Roof
Will Oe,ppli for future Milds cupam store or handle ha�ous material
az OcOncd ty d.Cu no unicipal Code,Chapter 9.11,and the Health and Safety
.dc,S❑Ya d,0.25532(.)? All roofs shall be inspected prior to any roofing material being installed.
u
Will the applicator car mime Mailing Occupant nae cgmpmcnt are Jcvicea whichIf a roof is installed without first obtaining an inspection,I agree to remove
it It Units air commom dcGrmd by the Bay Am.Air Quality Management all new materials for inspection.
mel?
by.
IhaverWNeluaNnusm
rUi ¢undehpter6.95of Ne Califm
nuHalth&safet ,Sccdonsalsmyuimm93rCdrstam thmif ¢Wilding
dote not cu
a laic tenant,OJtJd u my reapm obility ad nod fy Or occupant or the
requirement n mntbemetpn eanccnifiaa;nr17ce9pa,. Signature of Applicant Date
5' 'OS All roof coverings to be Class "B"or better
Owner or auth n gem Dam
Community Development
10300 Torre Avenue
i ✓ Cupertino CA 95014
Telephone(408) 777-3228
�
CITY OF Fax(408)777-3333 UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
LI &EIZTy GT. 0S OS ()p
OWNER'S NAME: T'GT EYL W oNN e-j PHONE # 2S 3 —I z-1 1
GENERAL CONTRACTOR Upt:Y -r I"C> ?WM& FAX# ZS3 Ol�-l5
I am not using any subcontractors: 45 . Cl dS
Signa Date
Please check applicable subcontractors and complete the following information:
61 1 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
7C Plumbing p t ruc,�l v 1Vi 8 t N (o t Z
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/Contract e Date
Wv, CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE u
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
17`7-0. 1 OcoL4 5 . 9 .os
Building Address: 6121
121 L- 10E1:Z Y
Owner's Name: .PETC-�Z W ANGi Phone #:2X5 -72-I I '
Contractor: License 9:
GV P£t'LT I Y�,J 6 "P LU M(2>1 N
Contact: �2�V IL LY2171 Cuperti ZBusiness License #:
e,01
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
eDPPErz 2EPlPE � 1/s/ATEY2 5�12VIL�
Residential Commercial ❑ .
Cost of Project: 000
Qty. if
Applicable 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
07
v
•
Community Development
1 Oemn
Cupertino A 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
lOD(�S rr /L® 9 20/ 4 OSOSoo 1-( 7
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR 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 00/d Crc,-ft' 31 8 37
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date