09060164 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10160 MILLER AVE PREMIER PLUMBING ANT) REPIPE 090EW64
OWNER'S NAME: INC PERMIT ISSUE DATE
S A CONTROL NO.
(408) _ 903-8184
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O O LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z ie with Section 7000)of Division 3 of the Business and Profe491!2ssions Code d my license is
'may in full force and e COPPER RE—PIPE FML BLDG SHUT—OFF THRUOUT ENTIRE
j n? License ass Lic.N
jr
C_,M Date Contractor BLDG; REPLC LIGHT WATER HEATER
ARCHITECTS DEC N
a< I understand my plans shall be used as public records
�yU
w C H Licensed Professional
n
03:5 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,4204 Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
a Z y prior to its issuance,also inquires the applicant for such permit to rile a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $19000
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). 375010:)2 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
ccuse Taw does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
It.
and will maintain Worker's Compensation Insurance,as required by Section
7 of tie Labor Code,for the performance of the work for which this permit is issued.
My
./Y/
ERTIFICA E F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z . CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that there is a construction lending agency for the performance of
(Y,> the work for which this permit is issued(See.3097,Civ.C.)
W Q L.endces Name
�
Z
L.cndces Address
U 0 1 certify that 1 have read this application and state that the above information is
V. correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
GL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Col liabilities,judgments,costs and expenses which may in anyway accrue against said City
U Z in consequence of the granting of this permit. Date
Dare
HAZARDOUS M ALS DISCLOSURE Type of'Zoof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and safety
Code,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant orfuturebuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hit hazardous air conuaminaptg gVdcfined by the Bay Area Air Quality Management all new i naterials for inspection.
Jlstricl? �J�
❑Yes ❑No
I have read dee hazardlxhs materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 75534.1 understand that iCthe building
does not currently have a tenant,that it is my responsibility In notify the occupant o the
of a Ce tc�tc o Signature:of Applicant Date
�� All roof coverings to be Class'J�"or better
orized agent Date
CITY OF CUPERTINO oqo �Oc)
REPIPE/SEWER/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # Date: k)-ci I Oq
Building Address: vq�
Owner's Name:
Contractor: `'m Phone#:
Fax #: tC1
Contact: Phone#: L p L�CJ a , I 1 c5 cry
Fax #:
Contractor License#: rig
C1
Cupertino Business License#: '230
8~1-
Job Description: L'�
ion: �U 1Ci�1 hC l t l+ '�1'1,(�J.t
oC Pi's h r'P
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N
[�tC�
Residential `6 Commercial ❑
Valuation: ', ! )--D
(� qI O V
Project Size: Express Standard Large [ Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Stanc.ards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF C UPERTINO
REPIPE/SEWERTvIAIN SERVICE
OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standard:; Commission B ALL PERMIT
Fee TYPES
1 BSEISMICR Seismic Residentiz l P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
r 1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1 PPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
I 1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Pi ging System P
1-4 Outlets
to
Gas Piping Systerr. 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Ch-,ck P
1 PLMBINSP Other Plumbing/gas Insp. P
/ 1 TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
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