01050081 ( r
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10804' BROOKWELL DR ' BELL. PLUMBING INC :' 01050181 .:
,. B DAT OWNER'S NAME', ' APPLICATION S -
1 112420, PRIJNE-AVE �S7�if31c0¢�1.
• • "^ c.' - - SANI PARY NO. CONTROL NO.
is 4t�6—SZ65 (5.10x438-gloom `.
❑acZ ARCECT/ENGINEER - - BUILDING PERMIT INFO
BLDG. ELECT .PLUMB id
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LIC[ SED CONTRACTOR'S DFCLARATiON
?y G I h -hY'ff' d f 1 I' .ed I p l rCl pf 9( g a Job Description :
t..,tow w'fhs l 7000) ID nlnf lheN it fess' seoee.and ny License -•
< t' f"i1flrceand « REGIF-'E:FROM' GATE VALVE--UGL TO -F-IXTURES.
Liver�
Dan, e✓ uE c ,.cosh BUILDING.
N 3 w vii An,died
UECLARAT N - (�
1 dr:r I Illy plan, h�IIM1 il aspbI' J. '
o ,Liprosedr r:
OWNER BUILDER DECLARATION
I handew air In l l in.over,fir h C f f Furrow Law for one
Z Q following reason.(Section 7031.5,Besibre,and
nnreef ng w lL Sed on tlwm' Profession,
The 9t s' Code, y cry eolnty
which requiPwproof to constrit matter,depoluo,or repaircity larri
necrosis also bedurnesthe
applicant f hreturn I y damem❑ h M1 licensed p I theproverm Contractors License Law(Chapter
Cha lag
--
>
lz
new lord o code) Sq. Ft. FloorArea
or t trroustandhe ha b
erthed fion Ary,violation
of Section 15bYaryaplot at4i csdhe IPIn civil poorly
fit., ethan Five nna,ecdclana - Va-
luation `
,.,
(ssdm. - . , APN Number � . � 'Occupap
❑I,as owner nfthe property,orrbyanfployeas is th wages as lheirato camparsed.a -will do the work.ande I I tltnad ,,offordf 1 (Sri.7044 a39 ] 05c ��
Ba.' d P fess Coda:TI C, f➢d L L does n P '1
l apply In an s w red Inspections
owner f property Wn hufld:or iprrovtherron.and%no does such work n mselt
or through his own mnuoyeas.Invented that such... re,rh ems are not intended or - - -
offered for she.IL however,the building or improvemau is sold within one Year of ' . ° 202 — UNDERFLOOR. PI'UMB ING - .
imnpldsau the "il'ohuilde"kill hove the burden of proving that he did not build or
mrofor lrosec of arle.). I -
pve �¢Ii -,:ROUGH 'G1_UhiBIMG ,
171,as niers,of the property.am escwaively emd�aceng with licensed contractors to - 502' — FINAL,PLUMBING ENERGY.
Lonstruct e pmjm(Sec..1044.Business ess ane Pmmi;nes Cole) he Connamors -
th
ice Law does not apply to on owner ofpropeny who builds carimprove,;merenn, 507 — FINAL F'LLIMH I hIG -
anJ h acf
contract, 1 Irejaid,with I fcter(O e p sterol l the
Ow Dal
WORKER S COMPENSATION UIiCLARATION T '
1 hereby ofrnn ander penalty of,w,jruy one of the hollowing dcclamlon s: "
° 1 have and will mninmfn a Cenificate of Consent 10 selGfnmre for Worker's -
Compensati.n, as f provided for by Section 3100 oda Labor Code, But the '
Left o..ranceof the work for which this permit is issued.
°1 have and will amount nt Worker's Contpenallon[alliance,aCociplo ed by Section
.3700 of the Labor Code,fon the wiformunea of lite wad;fon which this pit rnill is -
issued,My Worker's Com emmion Inssnnnea wrrienmJ Policy nunilror ore: -
1 r 2ND: ,)M0-64Z-4.
Carrier: -
CGRTIFICATION OF COMPENSATION
INSURANCE FROM WORKERS' .�
COMP[NSATION INSURANCE
'a (H section need nor be couldeted I file Fermi is fnr one hundred dollars ,
151 con or
1 verify that in the perfinnonex,of[let He for which hills Peru,,,is issued,-I r - -
'fail'inal eipploy any person in any neanner satku leanIn Ban to sabpet to the Workers - -
Compunsalon Laws of Colifmpia.Data'
Applfdan . - -
NOTICETOAPPLICANT If ffe,norkinge Cnt f fP p( fym could -
-Z discrete subjectt the Worker's Caropensation provisions ofth b L do yo fast
O.z Ul thcvnply with eachpnowitilun,ore isprniI xhill bed areoked.
z ..
^ V]
CONSTRUCTION is a ON I ENDING AGENCY
5 •I hereby or affok that d construction Ending 7,Or.agency for the pedor(lance
W of the work far which Ihw p.r n is seuW(Sea.3091,Civ.CJ - -
�.{� Lender's Name s
Z) Z
Leal Address
UO Icenifythm l Love read tnisapphamicnane.tmetmn menho"undormof(oa i. -
W ,fit corned.1 agree m comply with all city mW county ordlnnces unit stem laws relating '
- 0 V ooh Id y 'uncoil I hy" th, p 11 ffl cityl ll upon
{{...y� the idatc-pperioned p,Is .
F. VV) iliablf(Wa)46 ree l acre and efy and.ca keep ll may'n afyc laof yac Cupertino
agant id -.
APCitPLICANin Tgl encao " as e 63PLY WITH ALLN V,P NT
t- SOURCF REG ( Issued by- -e— . r-:) Date
Date
Clgnamre of Applirid/C. rambr 'D to Re-roofs -
HAZARDOUSMATERIALSDISCLOSURE ; _ -
Willthevpplicaotorfmme'btdldingnecaPon care orh:mdle hmnrdonemaerinl Type of Roof - • - .
as defined by the Cupnnlne Manic,a�Chapter 9.12.Iced the Health and Safety '
Cade.Section 25532(a)'1 `
°°`a - All roofs shall be inspected prior to any roofing material being installed. '
wd1 me apphcam or Boone lauding occupat use egaipmaaor devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hatwidous air conmminonh as dapped ny the Bay Area Air Quality Management
Dior ell' -all new materials for-inspection. Applicant understands and will comply'with'
°Y`a . .. all non-point source regulations.
T love need the d certals requirsholl under Chapter 695 of the _
California Health A,Safety Sections 2550525593 d255A41 d a dtbaf •-due
h h Id' gJnen no, h�svu—t to I�113y,�,,,ohl'tyt yUncu p ill nitce of a sen reals of
Occ p y
5 /p' Signature of Applicant Date
ow l on",goof
•D.he 'All roof [o be Class "B" or better . -
OFFICE