01090115 CITYBUILDING DIIVISSIION�OPERMIT ' CONTRACTOR INFORMATION:'-
BUILDING ADDRESS: PERMIT NO.
18969 BARNHART AVE MIKE COUNCIL PLUMBING IN 01090115
OWNER'S NAME: APPLICATION SUB DATE
itsDEBBIE RANDY BASSETT 1977 O ' TOOL AVE 09/26/2001
PHONE: (408) 272-4900 SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
p 0 0 ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
m
.�.r<a
Zy LICENSED CONTRACTOR'S DECLARATION
=G 1 M1ereby off rm that I nm licensed underpmvisions of Chapmr9 commencing ]Ob Description
atm with Sermon l000)ofDivision3ofthe Business and�mfessio m�icense NEW WASTE WATER LINE .
f Y is in full force on ec (0 7
e < License
x ABS 1" COPPER WATER LINE.
2 O U Data Contrecwr
e 3 a vhi RCHITECCS
DECLARATION
< 1 undeourad to,plans shall be usstl i s public recurs
1
cO O Licenses Professioml
-s OWNER-BUILDER DECLARATION
u I hereby.(Sero that 1 our exempt from the Cocos License Law for the
(_ G following reason.(Section 703 1.5.Business antl Professions ons CoCade:Any city or county
F C
�n3m ..ptorh tahhat Aets is eexexmPermit
erm n frvm and tvhexlbmar improve,r rhe adliemgegf a or repair my stunurtwht t e alsorequires tho appl'cxnto III
i'maditatement.
ludislicameilx stdfmtbeprolsrons fin Contractors License Law Chaffer 9 $q-.'F,tttF.,l,oor--
--
aation
ines(commencing with Section70007 of Division 3 of the Busm7x ;k
pub
Any violation
of Section 70315 by any applicant for a pensm subjects the applicant to a civil Penalty'
of not mom than rive hundred dollars(s5110). umber Occupancy Type
❑I:as owner of Ne propeny,at my employees with wages as their sole compensation,
will do the work;and the slNcture is net intendedoroffered for sale(See:7044;'
Business and Professions Code:The Contractor's License Law does not apply in an 202 - UNDERFL0QRuiRR1D 9KfWs'
ewrer of property Who builds or improves thereon,end who does such work himself !
through his own employees provided that such improvements are not intended or 3 01 - ROUGH PLUMBING a
"offered for sale.If,however.the buldmg or improvement is sold within one year of
completion,the ownr-builder will have the burden ofpmvmg that hedid nutbrald car 3 0 2 — TUB & OR SHOWER
Improvefimpmpnsenfsale.). 502 - FINAL PLUMBING ENERGY
. .
171.as owner of the prpeny.um asclnaively contracting with It a an oil comcunms to _... 506 ' —* GAS TEST
con,wnthe does net 7044,Bemero and Podfissaiiers >Th<centhmo, 507 — FINAL PLUMBING
License Law does .t apply t an owner th propeny who) Id proves[hereon, `7`7
and who contracts.for h projects wM.e comrecmr(s)b sed pursuant to the-
e
he .... .. .. - ..._. . .. .. . ... .. (. . _. . ., ..
Contractors Lucerne L
❑Ie eempt under Sec '' � B&PCfo thi reason � t^'�
Date
t WORKERS COMPENSATION DECLARATION
1 hereby affirm der penalty of perjury of the following declarations: 0
❑ I have and'will mmmnm o Certificate"of Cousent'm self-msurt for Worker's
Compensation, as,pmvided for by Section 3700 of the Labor Code, for the
perfamunce of the work for which this permit is issued.
711 have and will ma tarn Woilar's Compaccusillion'Inaturanati,as required by Section
Craned. Pah<Y Na this perm t s
.. .,ru d MY C ton In r d Policy arc
3700'off the Labo C de or the performance o t t
cY mbar.
;+
i CERTIFICATION DP.EKEMPTION PR Mt OR , 1 1( kj.t rpt �'4 Yi !' ➢ i' s s I ` t i -
COMPENSATIONINSURAICE .._...... _... ."._. ... -_._.- ....._-__ '. ..,(Thissecft need not be completed if he permit is for toe hundred dollars
is
. I eenifY thaun th pelf nnc
bee of he work Cut which his pemot 'sohd'1
shall nol eemploy any Person in any m n r s m become subject to the Workers
Coirrumnition.Laws fC if"im Date
Applicant: .
... . . !
.NOTICE TO APPLICANT If,aft r molding this Certificate of E mption,you should
be subject t the WorkeraCorHIpensation previsions f the Labor Cut you must
O Q f nh ith comply with provisions h o this permit shall be deemed rc ked t
t ... .. s- .._... . .
CONSTRUCTION LENDING AGENCY
(hereby"Rim thmth o t ct 1 dogagmyf th perfo "ce' 'i '.'i .I„!
Wr� ofth rkforwtihth pe nisrssed(Sec3097,Civ C)
(i
L oder Address
,.. .i t y,
1 ten a that 1 have reatl[his appl t andsanction the above information is '
ITa [.w coved.l agree m comply with ell, try JL
inances and state laws mlaring
to building construdion,and heron auudives of this city m enter upon
thebovemonilated ro ert for' e(We)agree to sabe'ind— fyans theCiiyofCupertinoagainst
a and a penin any way accrue against said
U-4' City in consequent gmnti g of ”APPL CANTU ANDS DWITH ALL'NON-POINT"' IssDedb
co 0 EkEGUL ON
1: y: Date
licaral
as def ed by thpPCl cant ntfuture iba la ng occupam store Dare
Re-roofs '
g P, HAZARDOUS MATERIALS DISCLOSURE
?, o hanm n aro smareval -Type of Roo£'J
tV 11 thea ,,. .
Cupenm M pal Code Chapter 912 and NCH lth and Safi ry
Code,Section 25532(x) 1
17Y— t ❑xe i'tf ' T.,,' '� l ; . -All.roofs shall be inspected.prior,to.any.roofing.material being installed..___
Will the applicant or future building occupant use equipment or devices which If a roof is installed''without first obtaining an'inspection;=l'agree'to,re-move
g cousin
DDistrict?emit hazardousarc tam t as defined by theBay Area Air QualtyMn
all new materials for inspection. Applicant understands and will comply,with
❑Y - on all non-point source regulations,
1 looo'.. di hazardous' tenals regmrcrobts under' hap o:695 of the
CnI f antl eat S t 05;25533 end 25534-1 understand that
as Sen Code, tions255
,if the building tc y put it is mYresponsibility mnatifY the
'otcuphof ofto to em win most be met prior to is a of n Cenificate'of
r'
Occup,anty;:.
- Signature of Applicant. Date,...-.
aptnnd:�a en Date,, All roof coverings to be Class B"'or"tietter "
OFFICE . ., . . . ... _ .... .....: ._ .. _ . ..
4�:! . Irl-