00090159 CITY OFN DI IN
SIONo
BUILDING
IPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRPSS, PERMIT NO.
1
OWNER'S NAME: APPLICAI ION SUIS DATIi
15973
PRONG: - - AW
SANITARY No. 1'
' -gyp
•,.L+100 AIICIIIT1 iCl/IiNGINELR: " ' - BUILDING PERMITINFO
k {- BLDG 17I.BC1 PLUMB MECH
rii a si - C
y LICI Ill.,I IscaON.RACI..durdit'S DECLARATION
law Job Description a
rO Z= thereby SR)or iM1n3liceased...tier provisionsof Chapter9(commencing
F w� wits r man nn3 �.� l rate Bt. -:,an,nPodficl chidet1mr Resort -
ais inf llfrc n ff -!' -
3� CP-�i7 10639� - P [Rik
Ern Z�y • ARC jn T S DI CLARAi ION,, V
5C O S deLr ttd��J�a�JJny - I - d:s 1 m DECLARATION,,
.O 'rtR.rerl a
OW NIR Bf11Ln1 fi DECLARATION '
n ny lrr, Il-tI pIr d cm ct 'L n: 1arr E
4dl g social.inns B .- dP I. ' C Code:Ad, ity j
❑ wit h I t , alter.- p d I'h 1 Y.t murc
e'3$ for I t I requires In ppliI I h pc I L tire vimcd cerement
mala licensed p u n p nn c Val r Lc Ia lchptar9 S FL Floor Area Valualiom..
- (cn eningwithSection VllanofD'vt' m
3 ftireBa. c udlmlewd
innaC, d q"
or that be is exempt therefrom and the basis for the alleged exemption,Any Nulaima
or Section 70315 by my a pp]molirapermit xobjecteo bi apPlicnnl 60 acivil e,,alty .
of not more than the hundred dollars 6500). APN Number ; - Occupancy '
❑1,m rather of the pmreny,or my employeas with wages as thcir sole co mins ficin,
will do the work,and the d nnwv is nil iinladed or offered liv'sale(S..]BW,.
firsin s,and PrnfdWeds Cole:Tha CnnWiwr's License Law does not ipply Io an Ketlulred Inspections
owner of property Who huilds or Intpmves thereon,and who does such work himself
or through his own employee.d.pmvidcA that suchimprovmems arc not intended(it '
'Eared for old.if,natatorial.tine Wilding ar impfnvemem`fc hmld within one year of 202 UNDERFLOOR PLUMBING
completion,the iwnerhuilder will have tine burden ofproving that ho did not bWIJ or
ad.....forpatpn.anr.ale.). 301 — ROUGHPLUMBING
ol,trial oflheproperty,nor evousi.elycontracting with ii,damedcnnlmetunm 502 FINAL. PLUMBING ENERGY.
cnnotmet Ilia projrl(Sec:7044,ur.iner.amt P...L"in 1,Cn.d:) 11,Canlnarl" 50F.r — GAS TEST
License Lax'does alt apply man owner if pmpeny who Wilds mitral thetem, .
mal wtn"Wats ter.nen pmjeelr with :i onmtanorlrl..cell ed pinmar! m the 507. —-FINAL PLUMB I NG-
CnmZro.license Low'. - _
- ❑1 at,ase in tinder flee B&P C ti reason t
Owner Date - -
WORKER'S COMPENSATION DECLARATION y
I nerehy affmt under penally of lrerjary one of tha following daclarbid i - -
O ( have roti will mainuilii mCedilicaic or Con.,at to.df-insure lit Worker', o,
Compemenion, as provided for by Sierran 37001of the Labor Cade, for the
if move of the work to which Illi,permit ie Irmed. '
CI I hava and will muinndn Worker',Cimleneal,ni Invanmce,a,nolood,l by Semon -
3mB of the Lahr Code,for the performance of the work To,which tit,Term,i. -7 1
ln
rrial�(//Wq( ICCA`
Cokcr's Ctnnpen.aW'n Policy
I1FIcy... y at atJO
��CUICI`JONL—OPE)iHM111'ION FROM WORKITS" ,
COMPF.NSAI iON INSURANCE '
(This section need nm M complate of the .it's for one trained dollars 'IS HE)or Ie,c) '
. 1
1 czloly that in the phrfor ams of the v, k for wniclt this pernh is l..aed,I
shall not employ any person in any manner,an as to become.subject m the Workao'
CoLaTimation Liws fCalifomia.Date - - '
Applicata t
NOTICE TO APPLICANT;If,alter making IN,Cenificme of E,and tied, o.should
bcconm
ebjem mtha k C penal np '.' n ofth Lamal yon most QO fnnhwnh I aply with .,It prolikitow or this pe 't.hll be dearnallmsol -
Z, -
F !� CONS I aWi I> .10th IrWDIhC AGENCY
I hereby offind ' Here t lendon,ego y
to, he fell.....and,
it the narkfor which this permn i.m%adN
(See.3097.Civ.C.) ,
L Q Lender's Nance
Lend Address - •
Is
C.1 Q I dandify that I lit recall it application and danit'llhad do,abrol information is �•
[rr orrincl.I acce I ply ilh all city'and nIY d n n add dre In.,Wading -
Q 67 to build' g conottraction,andhereby a tho <reprevvionfle%ofdll artmaga t
W the adoolawmarooned pn to Iy far inspection inarpol, .
E. 4 ("'a)agree to sme,indemnify and keep harmless the City of Cupertino against'
it to liabilities,judgments,cows and c"toes which may in any way warm igainw slid t'
V z City in cmtsequence or the granting of this fill
1Li ENT , F.RSNA 1S ANDWILL COMPLY WITH ALL NON-POINT• Issuedl)y: - Date
2Oo
si I�iien aillZARDmm Hata Re-roots
HAZARDOUS A1dfERIA.S...SCLOSURC
- •wetmeeCapsett'mcommipalCoe.Chaitt.mmeransateHealton.mSafeal Type ofRoof t - -
isJefneJ by the Cupenini.Siunicipal Code.Chapter 9.12,and me Health and Safety - r
Cc.Stiun 25532f:J7 - '
• ❑Ye. - 0 N - All roofs shall be inspected prior to any roofing material being installed,
Will the appllcmllmmtYrehadtfirgmcupmnco, quimnentatde.ice.which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamrdnu.air contaminants as defined by the Bay Area Air Quality Management
Diatriare - all new trtaterials forlinepection. Applicant understands roti will comply,'with .
❑Yes 11 No - -
all non-point source regulations.
I hove octal the hanudnus mmcrinls regaitements under Chapter 6195 of the
California Health&Safety Code,Sections 455115,25533 and 25534,1 inal6 stand that -
if he Wilding lees nor cramentlycovert tenni that l .my ri,,tionsibilityt ulify the "
oe
1 4 o
theq 11 are p -In iss f I Carl of
3 vo nt Date
(_may-!�-_ �/yJ+\^ ` A 'roof coverings o be Class `B•• ?better
ll ovritb 'Cls
O n^ rigs — me Signature of Applica ..
OFFICE-