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04010145 (2) CITY OF CUPER'PINO ' "i' • ' ` "' '•? - - - BUILDING DIVISIONPERMIT CONTRACTOR INFORMAUW ,; BUILDING ADDRESS: MIKE COUNCIL PLUMBING INC PERMITND04010145 OWNER'S NAME: - PERMIT ISSUE DATE ONE: SANITARY NO. CONTROL NO. ARCHITELTMNGINEER: BUILDING PERMIT INFO BLDGELELT PLUMB MECH l� 0 0 0 Z LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am limnsed under provisions of Chapter 9(commencing p wifh Sectionl"I of Division 3 or 6.Easinc Pmfcesiuns Calc,end my liccnu is eor°n inccnlfnme na rze ,32 .@y9ifo�-gz(� 1 REPLACE SEWER LINE Li se Cl LIc.1r FINALED ,3Q ARCHITECTS D RATION y B'� I understand in,plans shall he used.,public mcmds oLicen J Proftaainnal FEB 0 5 2004 �to OWNER-BUILDER DECLARATION <2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the O yO following mason.(Section 7131.5,Business and Professions Code:Any city or county BUILDING K m 9 which requires a pemlit In construct,alter,improve,demolish,or repair any structure - yai poor its issuance,also requires the applicant for such permit to file a signed statement ££ 6 that he is licensed pursuant It)the powisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation z 3 (commencing with Section 7")of Division J of the Business and hot ColeJur thhe is exempt dEmfrom and the basis for the alleged exemption.Any=of wog r.Aas.aA Section7RILS by any applicant for apermit subjects the applicant to a civil penalty of 3'fD Ytv6 VYllWQrOO Occupancy Type not more men fin hundred dollars(3500). P Y YP 1,ax owner of the property,or my employees with wages as their ole eompenutud, will do the work,and the."came is..I of ffamd for sale(Sec.1044,Business and Professions Code:The Convanm's Lice.e Law does not apply to an owner of Required Inspections property who builds or improves Nemon,and who does such work himself or through his own employeus,provided that such Improvements one not Intended or offered for sale.IL however,due building or improvement is sold within one year of completion,the owner- - builder will have the burden of proving that he did not build or improve for purpose of .1.J. ❑1,as owner of the property,am exclusively convecting with licensed comments;to contract the project(Sec.70",Business and Professions Code:)The Commentsi Lt. _ came Law does not apply to an awnar of property who Wilds or improves Nemon,and who contracts for such projects with a contractor(&)licensed pursuant On the Contractoii License Law. ❑l am exempt under Sea BA PC for this...a Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby aMm under penalty of perjury,one of the following declarations: I have and will maintain a Certificate of Collum foself-insure for Worker9Campem gotten,as provided for by Section 3100 of the Labra Code,for the performance of the - work for which this permit is issued. 0'1 have and will maintain Worker's Compensation Insurance,as required by Section 3100 of Ne labor Code.for the performance of the work for which this permit is issued. My Workeh Compensation Insurance carrier and Policy numkr am: ut.[Lp\ Ca ''PPMMttpyJJ�G zo 14 6 CERTIFICATE OF EXEMOM WORKERS'U 11/Z 4%) COMPENSATIONTTNSURANCE 1 ' (This tial...it not he completed it the permit Is Toro.hundred dollars($100) or to..) I our ify that in the performance of the work for which this permit is handed.I shall not employ any person in any manner u as in become subject o the Workms'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Centricam of Exemption,you should become subject in the Worker's Compe.a0on previsions of the Labor Code,you mot .,O forthwith comply with such provisions m this permit shall be deemed revoked. '� _ ..,vy - CONSTRUCTION LENDING AGENCY [—� I hereby affirm that there is a construction lending agency lot the performance of ai > tht work fur which this permit is iuued(Sec.3091,Civ.C.) W Q Lender's Name z Lender's Address U C) I certify that I hate read this application and sum that the shove information is t!. F correct,I agree to comply with all city and county mainences and suite laws Elating to Q U building convection,and hereby authmtre representatives of this city to enter upon the 4[1 'Now-mentioned nupcst for penes purposewhich ms. G (We)eF..to save,indemnify and keep hamtless the City of Cupertino against sty In liabilities,judgments.of the gratsin of which may in any way acetic ageing saitl City U",� Aconsequence NDERmnVDS this permit. F.t APPLICANT UNDERST DS AND WILL COMPLY WITH AL1:NON-POINT Issued by: Date SOUR EGULAT 7. Re-roofs ago rc (Applies Ont o De - zA ATERIALS DISCLOSURE Type of Roof dl the appli ant or future building occupant nom or handle hatuhmous material as tied 1 me Cu nine Municipal Code.Chapter 9.12.end the Hualth end Safcfy c,Section 255J2(a)? p p y - g being installed. C3, ,�N„ All roofs shall be inspected riot to an roofing material bean Win the app cam or future building=upon(a equipment or dcv;eca which If a roof is installed without first obtaining an inspection,I agree to remove it hannious air contaminants as defined by the Bay Amu Air Quality Management all new materials for inspection. tract? CYcs I have mad the haran4a materials requirements under Chapter 6.95 of the Califon nig Heald&SafcfyCode,Stefan.25505,255JJ and2554.1 uT` load thm if the building Jots not currently haw a tenant.that it is my Espmd; m notify the occupant of the " aqui owhich I at nissuance of.Cent, f«a y. Signature of Applicant Date w rmamhori'rcJ esti p,„e All roof coverings to be Class"B” or better CITY OF CUPERTINO I REPIPE/SEWERS/MAIN SERVICE J �� OF CUPEkTINO PERMIT APPLICATION FORM APN# 1 � 0 Date: 8 ( ft d `l Building Addres . PYA c,,, arRso Owner's Nameh., Phone#: �'� Contract Phone: ContacPhone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Job DescriptionA //''�� l I rra ti- a Residential ❑ Commercial Cost of Project: . 'f ble Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bld . Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING 3 � 7