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CITY OF CUPERTINO
kicok, RAC�TOR. IINF0„.RM TION
BUILDING DIVISION PERMIT
3
BUILDING ADDRESS:
CUPERTINO PLUMBING
PERMIT No. 05110132
10173 SANTA
OWNER'S NAME:
PERMIT ISSUE DATE
RANA BOOTH
10297 S DE ANZA BLE
11/21/200173
SANITARY NO, CONTROL NO.
(408)253-0618
ARCHITEC TNGTNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hcmby affirm that 1 am licended under provisions of Chapter 9 (commencing
Predications Code. and my ]f
with Section 7=f of Division 3 of Ne Business and Professans- u
in Orfoccindafract.
REPIPE (DUPLEX #10173/#10171)
Lima. clew tree
Dam II - i3 . OT Contractor
ARCHITECTSPECLARATION
1 YP1 II he u lie meorN 7/7 —
LaAaiixe fessian
OWNER -BUILDER DECLARATION
I hereby alarm Nen 1 am exempt from the Contractor's Liecnce Law for do
following mason. (Section 71131.5. Business and Professions Code: Any city or county
which requires a permit to construct. alter. improve. dcmuitN, of club any structure
$6000
prior it, its iyuaMc. also requires the applicant for such permit to rile a Signed staLL'mem
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant In the pmvisions of the Contractor; Lime Law (chafer 9
(commencing with section 7000) of Division 3 of NC Business and Professions Cade) or
that be is exempt therefrom and the bass far the alleged exemption. Any violation of
3APR9F4R—r
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant M a civil penalty of--------------
not more than firs hundred dollars (5500).
❑ 1, u o of Ne PMPmy, M my MPIo with wags u Ne'umk eampensadon,
Required Inspections
q P
will do the work, and Ne structure is not intended oraResW fonale(Sec. 7014, Busims,
and Professions Code The Conuanor's License law taxes wt apply k an away of
s�� fp
ghhis
aaeasuchwoh Air bs
property who ldsmimpmv ssuch went
proerty whoc;pro Orin
[s0, a� ami
m oRlfwf
NatmchimproaementsmeOut f1taNrough
suchim improvements
�{rO
r®y {`AgVSHjtlp
however, the building or improvement is sold within am yens of completion. the owner.
ttj7�-1 ^)g9, Fttig/pl]
builder will haw tic Wrdco of proving that M did not Wild or improve far purpose or
ft�d_so
sale.).
❑ 1. as owner of the property, am exclusively contracting with Reacted contraction to
DEC /3 1005
M ur's Ll -
constrscr, the projett (Sec. 70x4. Business and Professions Cute:) Conuto
case Law does out apply to an owner of prapeny-who bunds or impmws Iherem, and
who contracts for such projemwith aeonupursuant the
aetor(s) leaned puuant in Contractor's
s .
Licevaw.
el
❑'xmax.ptumxr Sec .9&PCfm Nsnx—
Owner Data
�J
WORKER'S COMPENSATION DECLARATION
I herby of I. under Penalty of perjury one of Na following tecl=dmu:
1 hsrc aM will maintain a Ceetifiove/Conserv to coif -imam farwarYeYSCompen-
'
section, as far by Section 3700 of tc labor Code, far Ne performarcs of Ne
work for which Nis permit is issued.
hick this
%w and will maintain Worker's Compensation I... u ext by Section700af
Na labor Cade. for the pertarmanc of Ne reek for which this permit's issuaM1
'
My Worker's Co nation here ram . caroar and Policy martax, am: O
Carrier. f—&y Poliry No.: /'�S7 3o -p
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-
Cres taction need nolp¢compLeud if the permit's frcome hundred tonus (SIM)
of less.)
1 cmuCv that in to porloormucc of the work for which this Permit is Wind. l shall not
employ any person in any manrcrm as an become subject in the Workers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
became subject to the Worked Compensation provision of the labor Code, you mute
' forthwith comply with such Provisions or this permit shall W i coned revelled.
j CON
Ihcmby amisacONLENDINGAGENCY
thi Nu Nee sec ronswed3 lending agency for the pertormarax of
ch
Ns. work for which Nu permit s issued (see 307, Civ. CJ
Lantcr's Name
lender's Add.
1 I cattily that I have read Nis application and auto that the show, information is
' comm. l agree us comply with all city and county ordirure" and suns laws relating to
Wilding construction, and hereby authorise mpscenutiws of this city to entre upon the
' .W.-mentiaMd property for insluction parpWel
.
(We) agree la save. indemnify and keep Wooden the City tar Cupertim eget.,
j liabilities,judgmens,eosu and expenses which may In any way name against said City
in eonsega a ofthe RST4ND5 Ns DIWI
' APPL UNBERST AN LL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU Ec TIO \ t
L
Re -roofs
undMAZIplictuni/Cornfactorl 0 Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant i r forum Wilding occupant time orhandh h sardous material
as defect by the Cupfcxmw Munici al Code. Chapter 9.11. and the Health and Safety
ode. Section 25532(x)7
Ya
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
will the alplicanl future building Occupant use equipment or devices which
remove
mit holesmi s air contaminants as termed by im Bay Area Air Quality Management
all new materials for inspection.
D stria?
Om
I have mad Ne hvardtmsmaerias cquirememt under ChaPur6.95 of the Califar-
nsHalNdt cly Cjode,SYtias25505 577aW 25574.ImdersunA thnifNe building
dos t c nil m ani Nati y responsibility to nothe oc
tify the of tic
rty w lam bcmelpd as a an aefaccnjramar cupanry.
igna[ureofApplicant Date
All roof coverings to be Class "B" or better
g
0 ermaatherixct agent ' '
Due
CITY 0,
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRES:
/0771 12J173 �r� Al
PERMIT #
DS//Q /0 ;�,-L
OWNER'S NAME: 12a -n e-,—
PHONE
GENERAL CONTRACTOR
FAX # 253.61, 3
I am not using any subcontractors:
Si a Date
Please check applicable subcontractors and complete the following information
Owneridontractor Signature
Date
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
no I r5
(D ��
Roofing
Septic Tank
Sheet Metal
Sheet Rock
i1
Owneridontractor Signature
Date
i
E
(z
01yor
CUPE(,TINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
APN # /y �1 1 .6)l f
Plumbing Permit Issuance
Date: ) I ` 199 .M�
Building Address: l �\ I Q `� I (JPhone
Owner's Name fV , (//; �Ql
(� `n
PLUMBING
#: ^` .7
j�Llcu
Contractor:
oPI urn I I n
jJ
11
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License #�i
Contact: F 1 � 1 r
K 6-
PLUMBING
Cupertipo1lB/ausiness License #:
(o /
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
PLUMBING
Job Description: /� !` �r '�)- lf
(JV
Sewers
Residential F Commercial ❑
BPSEWAGE
Cost of Project: L/z
Qty. if
Annlicable Fee ID
Fee T)rcrrintinn
Fr P (:rnnn
/ PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
T Pbl . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSE WER
Sewers
PLUMBING
BPSEWAGE
Sewage Dis osalPLUMBING
BUSLIC
Business License
BUILDING