03100065 CITY OF CUPERTINO "I ell
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BUILDING DIVISION PERMIT E CONTRACTORANFORMATION I
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jBUILDINGADDRESS: CUPERTINO PLUMBING PERMIT N003100065
OWNER'S NAME: 10297 S DE ANZA BLV PERMITISSUEDATE
(408) 253-0618 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
00 LICENSED that I CONTRACTOR'S under provisions DECLARATION
�'uF I hereby affirm Thal I am lr OA R.under ndPoof Chapter 9(commencing Job Description
ZI$ with Scetion](M%p of Division 3af Ne Business end Profession CoJc,and my license is
Lie
aumrceandr tf ' .2 Je REPIPE/WATER MAIN
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g_ Data Class Contractor
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ARCHITECTS DECLARATION
£a'j IundcmanJ my plans xM1ell Mused as Public records
eo' Liccnud Profcasiunel D
OWNER-BUILDER m die Com ION
00 1 hreaso ailuro on 1 am exempt from Ne Contras o License Law lou the
oO following reason. permit 7031.5,Business and Profcuinns Code:Any city or county
<m which requires a Permit m cnnsuucL else,,impmw,demolish,or repair any structure
AZ< Prior its iuuance.also myuims the applicam for such Permit to file a signed statement 000
that he is licensed pursuant lathe provisions of the Coni=tur's License Law(Chapter 9 Sq,Ft. Floor Area valuation
2�'
(commencing wi in Section 7")of Division 3 of the B usiness and Proficasons Coile)or
2 Nat he is exempt fMmfmm and the basis for the alleged exemption.Any vinituon of 35611066 . 00
Section 7031.5 by any applicant for a permit subjects the applicant o a civil pcmlty of APN Number Occupancy Type
not more than five hundred dollars f5500). P Y -- -
❑1,u owner of Ne property,or my employees with wage as their sole compensation,
will do the work.and the swmum is not intended or offered for sale(Sec.7044,Business — t1�s@[(Q�,�
and Professions Code:The Contractors Liceue Law doe trot apply to an owner of 2 02 - UNDERF UMTS 1 NG
property who builds or improves Boeuon.and who doessuch work himself or Borough his
owncmploy¢s.provided Nat such improvemcnu are not intended oroffered formic.If. 301 — ROUGH PLUMBING
however,the building or improvement is sold within one yeu of completion,the owner.
builder will have the burden of proving Nat M did not Mild or improve for purpose of 3 02 — TUB Sc OR SHOWER
"le')" 502 - FINAL PLUMBING ENERGY_
❑1,as Owner of the propcny,am exclusively contracting with licensed contractors l0 506 — GAS TEST
constrct uthe Project(Sec.704,4,Business and Profusions Code:)The Contractor's Li-
mnseLawdoesnotapplytoanownerofpropertywhoWildsorimprovelMman,and, SO7 — FINAL PLUMBING
who contracts for such projects with a conn sclot(s)licensed pursuant to the Conuutor i
License Law.
❑ Ison ee.pul me,Sce. B d P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION _
I hereby affirm under penally of perjury One of the following decllo ions: -_
1 have and will mainuin a Ccnifrne of Collum to selhinsum far Workeea Co.,..
70311W','
en,u provided for by Section 3700 of On Ld or Code,for the perfarrumee of Ne
k for which Nis permit is issued.
I have and will maintain Workers Compensation Insurance,u teyuimd by Section
of Ne Labm Cade.for the performance of Ne weak for which thea permit is issued.
Worker�mpensatiun Inn rtiA,An cy NOYnumber arc:ier. i '1T'_ —21 3—U�_
CERTIFICATE OF EXEM MON MOM WORKERS'
COMPENSATION INSURANCE
(Thu section need not Mcompleud if IM fermil is form=hundred dollars(S Wif
or less.)
1 certify that in the performance of the work for which this Permit is issued.I sM11 not
employ any person in any manner so As u become subjmt to the Worker'Compensallon
Laws of Celifomia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certifcate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
�0 fonhwith comply with such provisions or this permiuhall he deemed tcvoked.
Z y CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for too,Performance of
Yd > the work for which this permit is issued(Sec.3097.Civ.C.)
1 0 Lender's Name
7,Z Lender's Address -
J C 1 certify this 1 have read this application and sun that to above information is
correct.I agree to comply with all city and county ordinances and state laws misting to
U building coniwctm,and hereby authmire repmsenutivn of Nis city,.tour upon the
4 shove-mentioned property for inspection purposes.
ti (We)ague to save,indemnify and keep humleu the City of Cupcnino against
h liabilities.judgment,costs and expenses which may in any way accrue against mid City /
..l z in of the gran
APPLICACNTCUNDERSTtng of Nis ran; COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGU
S—aj Re-roofs
Signal Applic nt or Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle haauduus manurial
as defined by the Cupertino Municipal Cute,Chapter 9.12,and the Health and Safety
.Jc, f ly.25533(x7? All roofs shall be inspected prior to an roofing material beim
p Yea ,pi.�" P P Y g g installed.
Will the applicant or future building da"Imat ase egmpment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hmardous air contaminants as Jcfned by the Bay Area Air Quality Management all new materials for inspection.
utrlcl7
❑Yes
1 have mad the huraNnus materials requirements under Chapter 6.95 of the Califon
min Health@SafctyCAdc,Sccdum255Qf25533 send 534.1 OnJcratardthmifthc building
Jens not currently how a tenant,Net it is my r motility a notify the occupant of the
,eyes cc`ocky/' mum�ny(/metAnOrions mar fcauofQcuparay Signature of Applicant Date
1 � / ./�_v( All roof coverings to be Class "B" or better
Owncro utivrizad.gem Dan
CITY OF CUPERTINO o S'
REPIPE/SEWERS/MAIN SERVICE v 3
CUPEkTINO PERMIT APPLICATION FORM
APN# / _ , 6 Date:
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Building Address:
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Owner's N me: Phone #: 3oaCJ
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Contractor: Phone: License#:
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Contact: U Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: Cd sp-el
Residential Commerc al ❑
Cost of Project:
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Qty. if
A lica Fee ID Fee Description Fee Group
PPERMPl'FEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFD{TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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