04120130C_ ITY OF CUPERTIRO
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BUILDINGDIVISION PI•i'RT"aU
BUILDING ADDRESS:
PERMIT N104120130
7553 RAINBOW DR
OWNER'S NAME:
PERMI TISSUEDATE
DEVOTA PAULSON
ONE:
SANITARY 140. CONTROL NO.
ARCHITECT7ENGINEER: ..
BUILDING PERMIT INFO
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BLDG EO `: PO.
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LICENSEDCONIRACIDR'SD LARATION
lob Description
ooby atRrm shu'1 am Il= under pa Orm of Chsper 9 (commencing
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with
Oml(tfDivWnn3O"mBuI.,doffPROPERTY
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LINE C/OLCaCONTRACTOR:
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BELL PLUMBING SOUTH BAY.ARCHITEC190ECLA
101
my Valu slWl Wusadu WEl
Licensed Professional-
.. OWNER -BUILDER DECLARATION
I hereby 4M. that am exempt from she ConuacUh License taw for the
following mance. (Section 7031.5, Business and Profusions Cade: My city or county
which requires a permit to cmnrum. alter. Improve, demolish. in repair my suucswe
,
pdono its Women; atm requires the applicant ronuch result W file asigned sukmcnl
WtWtislicensed pasuantto dmlvovislonafdmConurrmwsllares,Law (ChaPW9
(commencing wish Section 7000) of Dlvuion3 of NC Businessland Profusions Csde)ar
Sq. Ft. FloorArea//�'
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y - M.var
% Valuaysx-,•125
shat he ts esampt sherefrom and dm buts for she alleged esemptiat Any violation of
YYY / 9'/
APN Number
�} Occupancy Type
Section 7031.5 by any applicant for a pencil subjects she applicant m a civil penalty Of
not mare Nm five hundred dallier (531101.
36230020.00
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❑1,area».worthepapeny,mmyamployeeswUwawuftbmLe mpcmdart.
Required Ins J - - - ,
will do Outwork. and dmauacmm is not Intended "offered mnam(Sec. 7014, Business
and ProluWon Cade: The Conus ams Illness Law don Out apply m an owner of
' - - - q P ection`s�� • '•, - .. _ .-
propertywhobulldaarimprovesmermn, andwhodoessuchwmkhimselfar through his
awnemployea,pmvidedthmmhimpmw:menuuenotimen woRemdfwsak.IL.-
however, Ne Wilding or improvement It mid within am year ofcompledon, sheowner-
Wilder will have dm burden of proving that he did not Wild w impave fw purpose of
141eJ„
❑ 1. as Owner of the property am mclusinly commaling with licensed mnsracsan m
consumer the project (Sec. 7044. Bumness and Rofessiou Code:) The Caurxmr's Li-
cone law does not apply to m owner of property who Wilds or improv daemon, and
-
who mnttseisfor such prejemswide acanuacmrt0liarmedpm•a tan Ne CommittM
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License Law,
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❑lamacmplundersee ,B&PCfwthiarcaon
Owner Data
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WORKER'S COMPENSATION DECLARATION
1 hereby eMan under penalty of perjury ore of she following lac aadivic
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.,
I luve a ad will nowmain a Cenifiats of Cowenl to Ulf -alum far Wmkefs Cooper-
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sailor, u povidcd for by Section 3700 of the Lahr Code, for the performance of she
wont for which thin permit is issued.
❑ 1 haus and will maintain Warmes Compensation Insunn¢, as required by Semon
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37Wof Oelabor Code,fw Ocpmforma molsheworkfwwhichshisNmitisiumd.-
coni be am:
M Wadon,s Contra dIssuancectPiry oum
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Ca t lPo11cY No.: O �f- CI
CERTIFICATE pE(EMMON FRUMKERS'
"
COMPENSATION INSDRAN
(Thb section need notbecampk¢d iftW permit is ferone hundred dollars (S10101
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or less)
I coolly that in the performance of the work for which Nis permit is Issued, I shall not
employ any person in any mannerm an in become subject to the Worlecu'Compmwtion-
LawsofCalifomia.DaU
_
Applicant
NOTICE TO APPLICANT: IL after making this Ceniftam of Exemption, you should
became subject W she Worker's Compensation provision of the Labor Cade, you mute
-
formwish comply with such pronumms in Nin Permit shall be deemed muted.
CONSIRUCDON LENDING AGENCY
I hereby ammo that more is a construction lending.gency for the pertomnac of
the work fear which this poison is ivad (Sec. 3097, Civ. C.)
jLender's Name
Lender's Md.
1 ceNfy that i haw mail this application W sum that the salve Information is
.
coons, 1 agree to comply with all city and county Ordinances and sum laws missing be
Wilding construction, and hereby authWn mpmsenudves (trusts city in enter upon the
shove-mcnduned property for inspection purpoUs
(We) agree Io cave. indemnify and kap h IM the City of Cerenire against
j Iiabilides.judgments. cost and espy... which may in my way access, Maim, Wit City
in consequence of the gamin his Permit.
I AP LICANT UN NDS AND WILT COMPLY WITH y� NON -P INT
Issued by: Dale /
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Re -roofs
Type of Roof
Signtu�,@ApplicmVConuacmr Dam
HAZARDOUS MATERIALS DOSURE
Will the applicant or future building occuparn(smm or handle hum on menial
an defined by the CupeNno Municipal Code, Chapter 9.13. and the Health and Safely
ole, Sedan 2153x(.)7
Yu e
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Willthe applicant (tr tutu Wilding oecupem use equipment or devices which
sub hocardnn air conuminan u dented by the Bay Area Air Quality Management
all new materials for inspection.
District
Oyu No
than mad the havardas remains mquheoenu under ChapeO695 ofdm Califor-
.I.Health&Safety Cade, Scelims 25505,25533 and75534. 1 understood ihaihhc Wilding
dna ml eummdy have -the it my roo mulbility m andfY the occupanl or the
requite hic Clpsiormi anaaf'sCem . aroccu cy.
Signature of Applicant Date.
roof coverings to be Class "B" or better
owner
ar n Oren
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDR S: a
PERMIT # O n (Z O C 2
CA,
BUSINESS LICENSE #
OWNER'S NAME:
^
PHONE # og
GENERAL CONTRACTOR
,,,,�
FAX #
50•4-K b ucy jI am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
ontractor Signature
2 04
ate
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
4H
-L-Z-6 4
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ontractor Signature
2 04
ate
I$
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE G
PERMIT APPLICATION FORM
APN #
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Date:
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
Z-4(-7
Building All
PLUMBING
BPWSVCS
Main Water Service
Ic SCA
BPSEWER
Sewers
9 so 14
O er's N e:
Sewage Disposal .
PLUMBING
BUSLIC
Phone #:
U
ontracto:
Phone:
License #:
�u^,,RCfNp(90—
edz
2 0
Contact:
hone:
Cupertino Business License #:
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Building Permit Info:
Bldg ❑
Elect ❑
Plumb
Job Descri tion:
J,-1
Residential �1
-- mmercial ❑
Cost oeci:
f oj
2 I
(L
Qty.
Fee ID Fee Descrintinn Fre rrnnn '
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFDCTURE
Pbl . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal .
PLUMBING
BUSLIC
Business License
BUILDING