03070014 CITY OFCUPERTINO
BUILDING DIVISION PERMIT FONTRACTORANF,ORMATION:
Bu1LolNcnooRFss: RANDY BASSETT PERMIT ND 03070014
OWNER'S NAME: 18969 BARNHART AVE PERMITLSSUEOATE
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+ore
LICENSED CONTRACTOR'SDECLARATION Job Description
with Section 1 bereby affirm that I em licensed under provisions of Chapmr 9(commencing
== ction]000)of Division 3 of the Business and Profession Code,and my license is
^=N in full farm and effect,
LicenseClaaa LIC.N FURNACE REPLACEMENT
9 J Dam Contractor
ARCHITECTS DECLARATION FTwn h n d
e� I underuend my plans shall be used a public rccors8 II'�1111 U� ^
M Liccacd Professional
OWNER-BUILDER DECLARATION s1
I 1 hereby.(bete IMm Nee CoplaCoonI I am exempt train rit License Lew rte the 2003
O O following reaian.(Section]f1)1.5,Business and Professions Critic:Any city nrcounty5$ which requires a permit to construct,alter,improve,demolish.or repair any structure
_Zt prior to its issuance,Also requite&the applicant for such permit to file a signed Statement
�0 that he is licensed pursuant to the pmviSlanaofthe Coomctur's License Law(Chapter 9 Sq. Ft. Floor AreaUll ftlu ttioh
(commencing with SCCIIon 7")of Division 3 of the Busineuand ProfessionsCMe)or u
y $ that he es eaempl therefrom and the bull for she alleged exemption.Any violation of 37 5 09027 . 00
Section 7031.5 by arty appliaat fora permit subjects the Applicant •civil penury of APN Number Occupancy Type
not mopa Nan five hundred dollar(5500).
❑I,As owner of the property,or my employees with wages As their sale compensation,
will do the work.and the structure is not intended or offered for sale(Sec,7044,Business — W&I C
and Professions Cods:The Commeter's License Law does not apply to an owner of
re506 — GAS TESTtlfrC6
property who build,or Improves thereon, though,end who doe,such work himself or ugh his
ovocmployces,provided that such improvements Are not intended oroRered roulade.If, 507 — FINAL PLUMBING
however,the building or improvement is sold within oro year of completion.the owear-
builder .will have the burden of moving that be did not build or improve for purpose of
sale.)
1,a Owner of the property,em exclusively connecting with licensed computers to
convect the project(Sec.7W,Business and Professions Code:)The Contractor's Li.
citron Law deal not apply to an owner of property who builds or Improve themon,and
who compares for such projects with a cantsactor(s)licensed pursuant to the Contractor's
License Taw.
I sm(y�e1l/�pI under see B A P C far this mason .
0 � Y71Ga!/IAar 1)
Of RKER'S M E.NSATION DECLARATIO1
I hereby alnnn under penalty of medury oro of the fallowing declarations:
I have and will maintain a Certificate of Consent to selr-insure for Workers Compete _
sa0nn,As provided for by Section 3400 of tha labor Cade,for the performance of[be
work for which Nis permit is issued.
❑I hew And will maintain Worker's Compensation Insurance,As required by Samoa
37M attire labor Code,for the pertmmmce of she work for which this permit is island.
My Workces Compensation Insurance artier and Policy number art:
Cartier: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThB section mail not hemmple¢d if the Permit B for ane hundred dollars($101)
or less.)
1 cavity Nat in the performance or the work for which Iia permit is Island,I Nell not -
employ any person in any manner an as to became subject to the Workcar Compcnation
Lowe of c.lifo..i..Data
Applicant
NOTICE TO APPLICANT:Ir.otter making this Cr nifcam or EAcmption,you should
become object to the Worker's Compensation previsions of the labor Code,you muse
.J O forthwith comply with such provisions or this permh shall be deemed invoked,
Z N CONSTRUCTION LENDING AGENCY
Fw I hereby Affirm NU there is a connructinr lending agency for Lint lerrormance or
FC the work fur which this permit is iumd(Sm.3097;Civ,C.)
W Q Lender's Name
7 z Lendc,,Add.,
r,J 1 certify Nat 1 haw mad this application and Som Nat the.bow InformuiOn is
W(~ Coven.l agree to comply with all city and county ordinances and state laws palating to
�O building Convection.and bemby authored representatives Or Nis city to enter upon am
Igt above-mentioned propeny for WNCtian purposes.
gL (We)agree to sew,indemnify and keep harmless the City of Cupertino against
t,w N liabilities,judgments,cote and expenses which may in any way acme against aid Cit
C.)7 In consequence or the granting of this permit. / /2
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DS4��t�zw ate
SOL CE RE ONS. a
\ / ( Re-roofs
Sitnuus of Ap canUConuactor Dam �
�/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building Occupant slow or handle hammous material
As defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cale,Section 25532($)' All roofs shall be inspected prior to an roofing material being Installed.
C Yea ,6a P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II haasdau air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
i,lrict?
[I Yes ]6Nu
1 have mal Ne haaandous materials requirements under Chapter 6.95 of the Califor.
nia Health 6 Safety Code,Sections 25505,25533 and 25534.1 unt'cmand that tribe.Wilding
deal nal currently haw a mann.that it is my ramoraphility m nobly the weapon,of the
require rats must mer mire ,iaummora •rdOcamO cupmcy Signature of Applicant Date
own ranthO sdasent G7 All roof coverings to be Class"B" or better
n
u
CITY OF CUPERTINO
WATER HEATER I
CUPERTINO PERMIT APPLICATION FORM
APN# VS"- OT - G27 Date: , �vl ZA^i3
Building Address: $ 96 rn k a r-t n(.c ccl gr-�t nr
Owner's Name:/� Phone#:
' Kar%A 1 ge1r -
Contractor: Q License#:
Contact: OQ r Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: �—
Strapped ❑ On PItform Bonded ❑
New Location ElRe laceme
Qty. if
Appli bW Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BEN ERGY Energy BUILDING
BUSLIC Business License BUILDING
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