05080130 CITY OF CUPERTINO - 77;;
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BUILDING DIVISION PERMIT CONTRACTOR INFORMATION `
BUILDING ADDRESS: PERMIT NO.05080130
0126 wFqTArRFq ng
OWNER'S NAME: PERM17I71951JEDATE
GLENN VENTURA 005
NE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERM"INFO
BLD13 1 ELECT PleUMB MECH
300 LICENSED CONTRACTOR'S DECLARATIONt. "Lyi O
Ihcreby affirm Nal lam licensed under movisi.ns of Chapter 9(cammenang _ Job Descriptionfl
n� with Section 10(10).(Divivan 3 of Ne Business and professiorm Code.and my Homes,is 4t� '(•(J�/
2fnfull force andaffectt REPIPE & MAIN WATER .LINE
? Liccmo Clans_y —3G Lic.p y�3 E/ �//
n F q Datc Contractor 0
' O ARCHITECT'S DECLARATION
understand
� I undtanJ my plan.hall be used u public records
k 0 Licensed Pmfeasionai
OWNER-BUILDER DECLARATION
COR ION tto11// R\J IfM/ /)ItO
0I I hereby.(Seto Nal 1 1. .Burin from due Comms Co License taw roc the U IVV/
00 followwhich re moon.(Section IID construct,
Business and ere,de lav Cale:Any city or county
$ten which requires;a Permit re firesth alter,improve,demolish,t orerepairsig any awmum 's']3
_Za- pnnrmiu lensed p,alsuntin for the applicant for such Mrmittoecorm Law(Chapter
8 that meminvedpusm3vtolhePmvisiou.fdmConuinm idttmelsw(CNPter9 Sq.Ft.Floor Area Valuation
E $ (eamm is exempt
itt Sutfrom and)th Divtaien3 th the Buunexemton.Any
�.. Net ha 4 exempt Nem(rom and the baso for the ailcgrA exemption.Any violation of
Section 1031.5 by any applicant for a permit ubjects lie applicant to a civil penalty of Occupancy e
tore N
t moan five hundred dollars($500), P Y EYP
❑I,u owner ottBe WopmY.ser mY wPloycts wIN vnguu Netmle<ompenulion,
and Professional
rCode: he Com boots
License
LAW dm
(not apply to H,B nor of Required Inspections
and Pro,whobu Cade:The Conuuton. ndwho law dam not apply lf rt owner of q p
propertywhobullroorimprovestherm.,and who areaouchwork Orofffser through his
Own employes,provided prmchimprosemenu are not IemuMmaaerttl for Owner.
howewa Ne building orimprovementisham edwithinid not year at mprowfrNeower"
builder will hew the burden of proving Net he did not build m improve for purpose of
ale.).
❑1,as owner of the propeny,am exclusively com using with licensed contractors to
construct the project(Sac.7044,Businw and Profession,Code:)The Conlsacmfs U.
cove taw dace not apply 0 an owlet of property who builds or improves Norton,and,
who contracts for such projects with a eonlnemr(s)licensed pursuant to the Conuamors r
License Law.
❑I am exempt under See. .B k P C roe Nis reason
Owner Dam
WORKER'S COMPENSATION DECLARATION -,,, ..
1 heabY alrnm under pevlly of perjury orc o(tm following dmluatiav:
I haveand will maintain aCemfcsm of Covent teself•ivure ferWarker.Campen"
tion,v provided for by Section 3100 of the Labor Code,for tau performance of the .. .."
work for which NH permit is issued.
❑1 new and will maintain Warkees Compensation hnurana.u required by Sector,
3100 of the Labor Code.for Ne Performance ardor wads far which this Amit is ivuW.
My Workete Compevadon Insurance tartlet and Policy number are:
Carrier. 4 4 0 rL D 'policy NaaA'DP"321 V Sr t—a
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs R:cit..Recd not Wcompleted If the Permit Is for one hundred dollars(SIN)
or less)
I ani(y Nat in she performance of the work for which this permit is issued,I shall not -
employ any person in my manner an u to bec.mombject to Ne Worken'Compevaton
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,serer making this Cenirium of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
.,z forthwith comply with such Previsions or this permit.h.11 be dcemW revoked.
'Z O CONSTRUCTION LENDING AGENCY
(-t thereby afnm Nat then is a construction lending agency fm Ne perfamana of
the work for which this permit is issued(Sec.HAI,Cl,C.)
�W Q Lender's Name
n`T. z Lendees Address
V O I certify that 1 have read Nis apPlicuien and sum into tau show infotmatun U '
comms I agree to comply with all city and county ordinances and sum laws miming to
O building construction.and hereby authorize representatives of this city In enter upon Ne
fA abovamemioned ro,orty for Inspection purposes.
P. (We)agree to sew,indemnify and kap harmins the City of CupmEna against
h liabilides,judgmenta,cosD 3M expenses which may in my ray accrue against said City
V 7 in consequence of the gaming of this permit
�i APPLICANT UNDgBSTANDS AND WII�Jr. Y WITH ALL NON-POINT Issued by: Date
SOU ATIONS. COMP�
Signature of Applicanvocnuactor`—"L- Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumy building occupant store or handle havamous materia
as darned by the Cupertim Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(3)1 / All roofs shall be inspected prior to any roofing material being installed.
Oyu V]No
1 Will the applicant or future building Occupant use equipment or desdas which If a roof is installed without first obtaining an inspection,I agree to remove
It hbJm.a]air cantaminmq u armed by Ne Bay Am Air Quality Management all new materials for inspection.
uicO
❑Yu No
I have mW Ne hvsmms materials requirements under Chapter 6.95 or the alifor"
fila Hula"Safety Code,Sauau 25505.23533 uu 25534.1 unAerNnd hast if Ne building
does wt cormntly"ham a Imtmt Net it u s ibillty to notify Ne aceupmt of Ne
myui Vichmustbemetpoor or accnircamofOcenpmcy, Signature of Applicant Date
G—OS All roof coverings to be Class"B"or better
..........he., .gem Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
RUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
10-32-6 w cmc fes /z
OWNER'S NAME: /F l✓ Gn U PHONE # 9G- 3006
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
69 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
C Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO ®
REPIPE/SEWERS/MAIN SERVICE o�O0 /3Q
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
lO esT car- P-G 0 (L
Ow s Name: Phone#:
L N Ve-v� 'r v R A q O4s -3oo6 uo* �q 2 z
Contractor: Phone: License#: 16 33 ,
�e Liv 2-. is 9-7 t4 L
Contact: Phone Cupertino Business License#:
Ga 20- GUt0l`z:E4=-3
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 15
Job Description:
/Z n
E $f/V !.-e— S T OrL 7�`O.�S AXn 14.4;P.V11
Residential Commercial ❑
Cost of Project: m _
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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