04060139 (2) CITY OF CUPERTINO .°�+. 'a dh:.m ^F.-t „�l' v. � " •`t u�.., __._._ ._. .. --
BUILDING DIVISION PERMITDONT-RAC:TO t jNFORMATION
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BUILDINGADDRESS: CUPERTINO PLUMBING PERMIT N"04060139
7752 ROBINDELL WY
OWNER'S NAME: PERMITISSUEDATE
JOHN CARROLL 10297 S DE ANZA BLV 06/16/2004
ONE:
SANITARY NO. CONTROL N0.
(408) 253-0618
ARCHITIr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�am Zp LICENSED CONTRACTOR'S DECLARATION O O O O
1 barely affirm that 1 am liamed under providons ol'Cluamer 9(ammencing Job Descriptidn 0 J� 1�LE®
wish Sc.ian]IXI01 of Division 3af she Budauad Profrsduns Code.end^y license is
inmRfoneandarzn. / // �`y 5 COPPER REPIPE
mgZ Licence Cl , Lk.N J11Ai sy�w rJ004
n
Data Cu ta.ar Q h' 1YY 4a L
ARC CI- DEC IONS
ILO g s ell d u rd, �N1qRI 11 eeeB,,�gV�g]]q
,6D / / SULLIY,V
30G Licc eJ Pmf hal Bq
OWNER-exempt ECLARATION avrYg
I 1 he y affirm that 1 am exempt fm variate Licence Law for the
EQ O following IEaon.(Section 7031.5,Business and Professinns Code:Any city or county
$iai which it
a permit at coosuuct,alus,improve,dcmulols.ar repair any sumctum $5000
prior m its issuance,also requites the applicant forsuch Permit to file a signed statement
< That he islicensed foment tothe pmvisiomofthe Con=wr*slJanxLaw(Chapter 9 Sq.Ft. Floor Area Valuation
as G (commencing wish Section 7000)of Division J of dm Business and Profess!
oa GMe)Ur
$ that W u exempt dmmfrom and the basis for she alleged!exemption.Any vio1Won of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of
oat moa than five hundred dollars(5500), a Occupancy Type
I,as owner of the papeny,or my employers with wag.a,their sole compensation,
will do the work end flaxamuctum is not etermcd ororered missile(Sex.7044,Business
and Prof.dons Code:The Connector,Liecam law does art apply m an ow.,of Required Inspections
propeny who bullds or Improm thereon,and who does such work himselfor through his
own employees.provided Net such imprownicau are not Intended or offered for sale.IL
however,the 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
sale.).
❑1.a owner of she property.was exclusively connecting with licensed contractors to
consumer the project(See.70ad,Business,and ProfoW ons Coda:)The Committers Li.
ecme law docs not apply in an owner of property who builds or improv themon,and,
who contracts for such pmjecu with a conmscmr(s)licensed pursuant in the Conmacmrs
Limc.taw,
❑ 1 on exempt under Sec B k P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby an=under penalty of perjury tote of t m following declarations:
I have and will maintain aCenlOcau of Consent to self-Insure for WorkehCamper.
Milan.as provided for by Section 3700 of due labor Code,for the performance of me
capula for which this permit is issued.
p�1 have and will maintain Woftes Compensation Insurance,a required by Secure
]00 of the Inbar Code,for Ne performance of she work for which this permit is issued.
My Worker Cam.lpp1eemeta an�n�ex.f...end Polity number
CaMer. �l� t'I�e Polity No.: -��I�DaP v
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not W completed If ibis permit is forme hundred dollars($100)
or lass.)
I certify that in the performance of the work for which this Permit is issued.I shill not
employ any person in any manner an as to become subject to the Wm1amr Compc...ton
Laws of C.lifomi..Data
APPlicom
NOTICE TO APPLICANT':IL after making this Cenifmcem of Exemption,you should
become subject in she Workers Compensation previsions of she labor Code,you must
.J Z forthwith comply with such provisions or this Permit hall W deemed rooked.
zCONSTRUCTION LENDING AGENCY
I harehy affirm that Nem is a construction lending agency for the performaa of
a 7 the work for which this permit is issued(Sec.3097,Cih,CJ
QLenders0. Name
0. z Lenders Addrens
V Q 1 eerti(y that l have mail dh applicatieffi-and sou,that the ahoy information is
FcrnecL 1 agree a comply wish all city and county ordinances add state laws mating to
O V building commuctionyandfmoloti uthndmrepresentatives (Jus city toenter upon the
W
above-mentioned pm ty frrinspecdon purposes.
L5. (Wc)egme ave•indemnify and kpep harmr the City of Catania.against
y Ilabilides.Juilli pus.C�nmrdCxpepasWhich � any y...a against said City
U z ineoaequenao�b of she'gryting of this psi I�%¢^
APPLICA M/U ER ANDS ANd BL- LY,WrTH?ALL NON-POINT Issued by: Date
SOUR S /
/ (-p Re-roofs
ignin of ApplicarVComm or Dau
HAZARDOUS MA R1 DISCLOSURE Type of Roof
Will Ne applicant or fa me (ding accupatstore or handle haaAaus mamnel
as ned by the Cupertino tpal Code.Chapter 9.11.ad the Health ad Safety
o ,r0Yea 35531(,)7 u All roofs shall be inspected prior to any roofing material being installed.
Y.
Will the applicant or comm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mu hevardaus oir coast imams as defmned by Ne Bay Ama Air Quality Managcmcm all new materials for inspection.
District?
❑Yes /
Ih C Mons v 3255ents 4.1undnder hapus motif the Wilding
nu H.jlm@ tyC .Sad , 33 wW]55J4.1 undcmatWeoccups Wilding
Jou ly m i u Net' ' Invisibility to twufy IM oceupat of du
regal m t r mec of Oanifi.uoree.pacy. Signature of Applicant Date
armor>ad.semt ate All roof coverings to be Class"B"or better
Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
2 /a&SCI' l I,JI- G 6�G/3
OWNER'S NAME: /-? lcrt�0/ PHONE # 253
GENERAL CONTRACTOR FAX # Z G
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 R ck
Tile
G-D
caner/Conti ct Si a Date
CITY OF�CUPERTINO
REPIPE/SEWERS/MAIN SERVICE C) li r
CUPERTINO PERMIT APPLICATION FORM
APN # .�_ 2-2 .010 ,t f Date: � .�L,oq
Building . 0 Address: `77x52 1P Cb I nde,41 OaL
Owner's Name: achy) C&rr0 I 1 Phone #:XCZ &/
I
Cont 0"
/I D 2 Phon!Z!53 O�/g License #:`�OC
Contact:, Phone: s Cupertino`/Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Descri tion:
Residential Commercial ❑
Cost of Project: ^�O
i
Qt
Y
iciibFee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING j
BPERMFEE Bldg. Permit Fees BUILDING .
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Dis oral PLUMBING
BUSLIC Business License BUILDING
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