02040024 CITYOFDPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
914 BLAZINGWOOD AV CUPERTINO PLUMBING 02040024
OW'NER'S NAME: APPLICATION SUB DATE
ANDERSON HAL D AND BARBARA A 10297 S DE ANZA BLV 04/05/2002
PHONE: SANITARY NO, CONTROL NO.
(408) 253-0618
c ARCHITEC(ENGINEER: BUILDING PERMIT INTO
as ed
BLDG ELECT PLUMB MF.CH
�<� U CJ L.J IJ
S K a LICENSED I hereby affinu r,It.li coo d unddeRr pro kC..Aof Chapter 9(commencin Job Description
iRATION
_ L withS«tion 7"ofDivisionSoftheBusinesseI PmfcslsiousCad e/.Viandmyliusc COPPER REPIPE, WATER SERVICE .
xE= is`[full Tercet 1.L�/ � ] L
:al nsc Class / Lic.a
i 1 h tae Commqur q___�-��
vo ITECrS DECLTRAT1016' c ` `-'
_ 1 undersand m�pini shall heated as public records
N
!EM Licensed Professional
'aOWNCR-BUILDER DECLARATION
so 1 hereby affirm that 1 am exempt from the Contmcmr's License Law for the
following reason,illation]031.5.Business and Professions Code:Any city or county
I ff e which requires a permit to construct that,inflows.demolish.or repair any diamond $5000
�3m -Prior tots issuance,alsomemos the applicant for such panel to file aligned segment-
thajn Ice dp , amt Chep i sof the CnmruaorsL L ICha ter9 p _
° g1� (� D Valuation
(commencingexempt
lliA rhe .lono Bad
mi rAn acme) f f . k i3671F 'lJ•�04.t ai{.'a�-t,
or thatSud he m tempi memftdli and the bats for the cts the exdcant to Any.Penalty "
-of Section]031:5 by any applicant for a prnnit subjects the applicant to a civil Penalty- ND�
mroom hundred 202APNU1v1u FLOOR PLUMBING'' Occupancy Type
01,as owner of the property.or my employees with wages as their sole cmn admation.
-wlll'do'the work:and the streadom is not intended'or'o fered for safe'(Sea:']0.U, )l JQeI PT QTN
'Business and Professions Cmc The Contmcmr's License Law noes not apply to an
of owner - Who blei
. inflows,
tn - d n d n km himself
. _ 5 0.2. - .-F.-I, NAL,- _P-_L. 9_E-pF-4m-_
sF$__4
1" 1_"�Y
01 forego
hisowemployee,,provided tbar.tchImprovements not intended or -
@ d Y If,hw he WillingP < t Id - y ar of " 7 FINAL"'PLUMBING
do,Inflation,theblei will have the M1N provingfthathedA notb 'Id or
improve far pmr,o'd )
rt 01. the properly. exclusively ic With dcontractorsto
cont project
( e.704Business I Profe Coca:)Th Contractor's
License Law does et apply t er pp who bill repwmereon
i
sortable,.coundelf.for such.propects,with.a contratcoms).ficarded"mosmano wm
License LawContractors
Gimexemp llndcS
B&PCfar this reason 1 )�, i ^••i,l;
Owner'' - •,, '' ,Clue' - l'
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penahy of perjury one of the following dcclarvtions:
..I. 0 1 Ea1'e and will'mainmin'a CenlGcae of Consent in self-insure for Worker's
Compensation, as provided for by Section 37W of the Labor-Cal for the
'Perfamsance of the work for which this permit is issued. ,
01 lo0a and will ruinuou Worker's Cltrpcniaucan insurance as¢qulrcd by Section
37W of the"We Code;for the Performance of the work for which this permit is
ismed.My Worker's Compensation I.....a c earrieeand Policy neard ra
cam NATE FvAJD'ipahryrr 7/301 UAllT000 - yy 1- >•. — -- - - " -
CBRTIFICATIONOFE%EMPTIONFROM WORKERS', Y f.I l 1.1 V, I a t+ 6d'!' i r',':-%;21 t I
COMPENSATION INSURANCE
... .,. - _-_._.__.. ... _—.. _....._-
$1
(This a nneW nor be eltm letld tone perms sltr one hundred details '','' . , )" ��,. y;
Ig100)or less) °
•.r - t.-.... . .._ _
e fy that o the o f f the;;.AT.1 a h u parrot red I -
Corporation
dedlor mploy any pe i y manna to become subject to the Workers r" ^
v. r
Compc .-i on Laws ofC if Data
Applicant
- .. .� .. _
NOTICE TO APPLICANT If,after k gih Cenf a .1 Estaron.you dvsmld -
becom'
sithess W Compensationp ' f LatterCee -must
forthwith comply will;such pr nsorth p shall be deemed revoked.z
F.� CONSTRUCTION LENDING AGENCY s11't.
6i I h by R th t theses m wn 1 d g gencY fo the perfo dance
.., afore m6fl,for 'h ch m s perm t is issued(Sec 309J C' C)
a'0 Lenders Name'-.. ` ..a. -..- .,.. . . .. .... _ . , ..,, -,._ ..l-
Lend ar's
..Lenders Add v' -.._.... . .
V I 1 centfy that I have mad this application and state that the above inronn llon is
<drrcci,L-,me to comply with.11 city mid coonty c rdireades mad state laws offering
'�'•.(, m building consimand hereby authorize re'pinsentaiveof
s tnis city to enter upon
tann
he amoementioncd property for inspection purposes.
fI.... R. ("'a)igrecrosix,:indemnify,and keep hasnlcss the City of Cupmine against '
L (Zliebilitics,judgmcm"us.and en eras which may in any way accme against said
U"z City in Yonne runt of m:: - rni 7this permiC '-
APPLI AN UN 5 fD WILL COMPLY WITHALL'NON'POB•IT-" ��
so t B u. f _ Issued by: Date
y 5 Q�
S. Dt i
U
HA us M IAIS DISCLOSURE f1 .� Re-roofs �5 �J
definedlbmthec 1ptf t renu BoWto
ccut re ohamle harardou i<'I .. v_ <2—
as yC, pen Mu p I Cod Chapter R 9 d m Health Type Of ROOF M1 a d Safety
Cbde SOcY 2553 C) TON .. .,,t"r ,.t Y r , }
..�. - -`� . - All roofs shall_be inspected prior to any_roofing material being installed.
W B the af t bas lin ed c pe t ftdwhich
emit h zardo s irconnmi a s defined b)the Bay Area Ai Oral oy Management If a roof is installed without first obtaining an inspection I agree t0'remove
Model'_loY - oN all new materials for inspection. Applicant understands and will comply with
all non-pomt'source regulations:
1 hovee lth the h z b maienals q mmems undo Ch ptol ...a df the -
if hfom,e Health&Safety Cmc'Sccdons 25505;25533 and 8534 1 understand that
ecce Id d oscura x h '.evv of niotify he
Occup m (lh "uvcm fi wh ch m'Tart.
m t t ¢of - -- - - -
., tXcupm .� � nun aresponsibilityt and •..
Y
1 11
l / p Signature of Applicant Date
_.
° m :ea I'M I �I, Dae All roof coverings to be Class"B" or better
OFFICE..
-