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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
p eRACT $ RAIIVX+'ORIVIATTON:,.
BUILDING ADDRESS:
CUPERTINO PLUMBING
PERMIT NO.
OWNER'S NAME:
10297 S DE ANZA BLV
PERMIT ISS DAAM
NE'
(408)253-0618
SANRABY N0. CONTROL N0.
ARCHITECDENOINEER:
BUILDING PERMIT INFO
BO ELECT PLUMB MECH
LICENSED COND(ACIOR'S DECLARATION
lb Description
ensed under provisions of Chapter 9 (commencing
1 hereby affirm that I am licensed
P
with Section 7010) ol'Divisiotn 3 of the Bu inessaM Profession, Code. and my license Is
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I�cII�f��ndeRect. Lie.
REPLACE WATER HEATER
FINALE®
Dsu Cie.4
ontrMuer
ARCHf7EC17S DECLARATION
I understand my plans shall he used a public records
MAR 19 2003
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I em exempt from She Contrmrs Lkenw Low for the
following mawn. (Section 700 I.S. Business AM Profusion, Code: Any city or county
BUILDING
which requires a permit in Conswct, aier. Improve, demolish, in repair any somehow
prior w ILL issuance. Rim requires the applicant for such permit to Ole a signed statement
Sq. Ft. Floor Area
that he is licensed pursuant to the provisions of the Common'sLmuc Low (Chapter 9
$W�"tion
(commencing with Section 700°) of Division 3 of the Business and! Protrusions CMA) in
duo he I. exempt fierefrom and ee basis for the alleged exemption. Any violation of
3 5�4N p
Occupancy Type.
Soction 7031.5 by any applicant for a permit Subjects the applicant to a civil penalty of
I more than Oro hundred dolisrs ($300}
1, AS owner of the property, or my employees with wages As their sole compensation.
502 - FINAL � $ ec&IFR
Illdothewerk,andthesuuctueisnot intended mothered fonsak(Sec. 7044, Bottom
and Profesaens Code: The Conuacwrs License Low does wt apply w an ewnu of
property who bulldsor improve thereon, endwhodotatuchwerkhimxelfortluough his
506 - GAS TES
ownemplotyees, provided wt such improwmants tae not lmrmm or Offered forsala If.
507 — FINAL PLUMBING
hewever, the building or improvement h Sold within ane year of Completion, sire owner,
Wilder will have the burden of pmvng Nn he did nm Mild in Improve for purpose of
ASIA.).
S1, an owner of the property, am exclusively contracting with licensed conncmu in
'
o street the pmjm (Sec. 70,14, Business and Professions Cade:) The Contrwtor4 U.
cense law dean not apply in an owner of property who Wilds or improves t ermn, and
who Coommus for such projects with a Conuactods)licensed So me, at w the Conuactol,
License law.
❑tun em der Sm. ,B& P CC7for this =an
Owner /f/ ✓ Dated
_
WORK 'S COMPENSATION DECLARATION
I hereby Mm under peaty of perjury oro of tie fallowing declandons:
1 have and will maintain •Cenifiese of Correct to self-insum for Wwhr'sCompen-
olon, AS provided for by Section 3700 of the Labor Code. for the perfermense of the
work for which this permit is issued.
- -
❑ I haw and will maintain Woftes Compensation insurance, As required by Section
3700 of the labor Code, for the performance of the work for which this permit is United.
My Werlows Compensation LuursnCr calla and Policy number sac:
Cartier, Policy Not.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(Thisseerlrm need notan completed if the permit Is forme hundred
Cr leu)
1 ceNfy that In the perfomanee or the work for which this permit 4 blued, I shall nm
employ any person in any manners an in become subject to the Workers' Compenaation
laws of California. Data
Applicant
NOTICE TO APPLICANT. f. after making this Certificate of Exemption, you should
MCome subject w the workers ComPetwdon previsions or the labor Code. you mutt
forthwith comply with such provisions or this permit shall be dcemed rewkc0.
CONSTRUCTION LENDING AGENCY
I hereby art that them is a construction lending agency ror the performance of
the work for which thin permit B Issued (Sec. 3097, Civ. C.)
.
finders Name
'
lenders Adder
I Crotty that 1 haw read thin 4PPlicaten AM me that She Above information U
comet. 1 agree to comply with all city And county Ordinances and me laws MAdng to
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building eonstmction, and botchy amhoriw rep rsentatiwa or this city in enter upna the
above-mentioned property for Inspection purposes
(We) Agate to Sow, indemnify and keep hamlets OR City or Cupertino ogalnst
IlabillfiesJudgments. costs and expenses which may In any Soy accrue against said City
in cmmquencc of the granting of this (emit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU/RC��tLATIONS�i' -311-142,-311-142,Re-roofs
Type Of Roof
si tare arAppuc.�mrcanuacta Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fame building Occupant tame orhaadle ham rdous material
AS &:fined by the Cupertino Municipal Cod:. Chapter 9.13, and the Health and Safety
ode. Secfion 25532(A)7
All roofs shall be inspected prior to any roofing material being installed.
Oyu ON.
a roof is installed without first obtaining an inspection, I agree to remove '.
Will the spplicam or future building «cuPanl use equipment or devices which
.If
It haurdnas Air contaminants AS dcOned by the Ery Arta Air Quality Management
all new materials for inspection.
Isuict7
❑Yea ❑Nu
I have read the hnndeusmaerlelamquiremenu under Chapterd.95of the Califor-
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niaHealth&SsfetyCode, Scerions25505,25533 and 25334.1 undcretand dtatlfde Wilding
does not currently have a tenant. that It is my responsibility in Redly tic Occupant of the
mqumFperMmygdmwinaa�aracedkearo3p3
Signature of Applicant Date
j =— /
All roof coverings to be Class "Bt' or better
v
Ow orm unixed agent D/me