01040077CITY OFCUPERTINO
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BUILDING DI VISION PERMIT
CONTRACTORINFORMATION:'-
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BUILDINGADDRESS: .
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PERMITNO. _ -
ALPINE
OWNER'S NAME:
APPLICATION SUB DAII!
AM Hni ms
2t
''PHONE
SANITARY NO CONTROI, NO
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ARCHITECT/ENGINEER:
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BUILDING PIiRMITI
9LfXi' ELECT PLid M[CH
LICENSIi D7CONTRAC'fOH'S UECLARA'I'ION
- Job Description
I hereby anion than I unr liceneed rmder 1101LTons of Charter 9 (comnwncin,
wllhs La l 71NNp U J fdCBU 'e JI Ifessio Gxlc and m)hwn¢
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COPPER REPIPE, WATER HEATER,
77�'rB'�H<fIi1FT'SDICIAN �7
WATER SERVICE. 3 'PLEX..
I Iantand my pr 1 +Liu rx asm 1 m d.
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FINALE D
Lunir ad Profenamal
OWNER- BUILDER DECLARATION
1 hereby affirm that I um empl from the Cnmbrab is License law bertha
following reaanm. Section 7olL5.Bnsiness and Profesime, Cadr: Any airy or county
] which mqui r.. a to construct. alter, improve. demolish or repair snucmre
.� AUG O p ^oo�
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Permit any
pdono iO I ... an ' nlsn...nice the applicant forxuch perntiuo file a obtain] staten0nl
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1 Sq. Ft. Floor Area '
YllllliltlOn
Ihm he iO fi,coalpurnuannol hepooloon ofthc Contractor'. Lern,e law lCau,"t9'
(u+mmencin, with Section 70Wq of Dlvi.ina J nub in
s Busess and I'rnl'csslons C.alCl
or that he ix axentpt therefrom and the bmis for the ullcged ei nnption. Any vaAatinn
BUILDING
of Section 7031.5 by any applicant for a Permit suhjea s the amliemn at a civil penalty'
of not more than five hundred!
- APNNumber
Occupal : 0'
° 1. asnwner ul the pmpary,o ui, employees with w,asuaheir sole cnmpensmion,
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will do to k aid the ,III mI intended or offered in odo 611. 7W4,
Baln 's t t 1 Icssb C 'I l Coulon, I : I t a se L does in( apply to I+
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Inspections '
< _ 326 j 507
mner tp Any Who holds r imp rveth d'whode ,wok himself
. CDLIed
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or through his own employee provided that such improvcmems am not intended or
atTemd lot sale. IL however, the building or itnprovemenl is sold within one year of
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immpletion.mcawner- budderwill have the hnrdenofpmmng that he did not build or
mprove for pacross, of salC), --
x 202 — UNDERFLOOR PLUMBING
❑1.asawna,a'Tltaproperty, ante. cfusivelycamtating with hcnrmdContmnrr10
301 — ROUGH PLUMBING
Limama. the Pcoset (See. 7044, Boars. and Professions Calao) Ilm Contractor'.
50c — FINAL "PLUMBING ENERGY
cense law does not apply In an owner of propeny wno builds or improves memo..
and who «mtmets for such project, with a confirratons) Reetnad Pursuant to the
507•”— FINAL PLUMBING
Cro a a,mr's Licen a Law. ,
° I um exempt under See. •, B & 1' C for This tenon
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Owner Dal[
WORKr:R'S Co %IPENSAI'ION DECLARATON
Ihdmh aRrtn under ilt f
y Pena y o .perjury one of the following Jcelluauoro:
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I❑ I nave nod will malntnin a Certificate of Consent to self-insute for Worker's
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Co' pensa kra. ded
by Section 37N) of the Labor Code, for Inc as
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pert L n permit in wed.
the work loch
Cl I base and will maintain Worker'., Compervad i Insumne , as regained by Senion
•d7 the labor Comic, for the Performance of the work for which this permit is
s '
e y W� 1 rs ceIWCa��^(}(/� nJ Policy numJGh.(r/[a�}��
Ris
C;ItTI��EMPT IONIIR :Its'"
Td�-
�V��y NSATION INSURANCE
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( ('This section mpleted if the permit is for one hund red dollar
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IS 100) or less.)
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I cam ry that in the performmnce of the work for which this Perot is issued, 1
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shall nth employ any person in any nmnnsr Cn as to become .subject to the Waders'
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G,mlmnsation Laws of CaliOanla. Date
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Applicant -
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NOTICE I O APPLICAN'C lf. alter making this Cenificale of Exaniption, you should
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became eabjeal to the Warker'n Compensation Provisions of the Lahr Code, you most
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forthwith comply with such provisions or this pcmain shall be deemed revoked.
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"CONSI' RUCTION LENDING AGENCY. %..
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I hmcby affirm that meta i. it'constnmtion Tomlin, a,en , far lIn, fif acre ni
of the work for which this permit is issued (Sec. 3097, Civ. C.)
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Leader's Name
lender's Address
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.agree to n anon is
lication and stem tnces
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corrI comply with all city and are, laws
ect. Ihgrco m comply all city and county ordinances ,city laws tdming
. d Ise
n....(y Iehy seal,fion eprcacnualve of 0d, coy wearer upon
the ahoingencti ad poopen Rn inr.puctike pnhennc,..
the ubo(We)
g as to .cast indemnity
(WC) a"cc one keep harmless the City of agninw
n
liabilirie 'nJgtnea nut.. J cap tus which may in say way uccrve again,. said
s con, against ai
Cityl f th sun 'n this Lenoir.
con, aC�
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A r RSV D VILLCOMPLYW NALL NON -POI
U ILL. �
Issued by: Date'
A,phaaR /Ca Inner Data
dkJS
Re -roofs -
• HAEAH MA IALS DISCLOSURE
Willtheapplienanrfmure Iccopen store or handle hauWous material
Type of
as defined by me CupeAnw Municipal Code. Chirpier 9.12, and the Hemet and Safety
Cale. Section 25532(a)^
°Yes 0 N
All roofs shall be inspected prior to any roofing material being installed:
Will mL'uPiiucan(dr fdlnra builoo,ont,am too ts,.ipmeal -ardr0,,, whah�
If a roof is installed without first obtaining an inspection, .-agree to remove
emit heeurdnus air contaminants as defsnsd by the Itdy Area At, Qdullty Mon.6emenl
Distinct,
all new materials for inspection. Applicant understands and will comply with
°Yei °Nn
all non -point source regulations.
.Luse ma the hazardous notterials regnirrinenb under Chapter 6.95 ot'Ihe
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Cml'omlaHaithh &Saf•y C Sections 25505, 25533 and 25534. 1 undemcind that
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u Ida It +e. note Idy,avea mount. .bout is my resrymsibillty to aotiry the
cup. 'th net ,rein a illuw be nil prior to issuance of a Cmifcate of
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Oce.,uaey.
Signature of Applicant Date `
_/7-0
All roof covering's to be Class "B" or better '
Owne ro
r.r:n,thmire t e.
OFFICE'