04090005 CITY OF CUPERTINO r�° '-"'
BUILDING DIVISION PERMIT QfiCONTRACTOR NF�ORMATION.;°
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BUILDINGADDRESS: AQUA FLOW PLUMBING PERMIT"04090005
OW
NEVES NAME: PERMIT ISSUE DATE
I
POORN N
ONE: SANITARY NO. CONTROL NO.
4082659504
ARCHDELT/ GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
D O O O
400 LICENSED CONTRACTORS DECLARATION IobDescri hon
e u C f hereby affirm that 1 am li¢nud under pmviakms of Chapter 9(commencing p
now with Section]IXM))uf Division 3.fOC Boureas and Proration,Codc.and my license is
d
at
Lie.M
full roaand errat REPIPE/WATER LINE FROM METER TO HOUSE
Lne,Class
F Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public record&
�yU
o G Licensed Professional
` 3
OWNER-BUILDER DECLARATION
3<p 1 hcmby.(Sera Nal 1 am eampl from me Contractors :Ad,C Law for the
0o followingreason.permit
RU L4Buaiter. and n.denim Code:x$ which its issuance,
a permit a construct.alter,Improve,dcmanit t or repair any structure
m—'^
prior mits issuance.also mquims the applicant for such permiuo file saigneJ summcm
< that he is licensed pursuant 10 the provisions of me Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
Valuation
m` n (commencing wi m Section 7(10(h of Division 3 of the Business and Professions Code)or
_ that he is exempt therefrom and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 60MI!'DLflacto 0 Occupancy Type
not mom than five hundred dollars($500).
I,u own=af flue property,army employees with wags as their sole eompenndoa, COW
will do the work and NC structure is nntimmnded oro@md forsake(Sm.TOCC,Business
and Professions Cade:The Commodes License Law does not apply to an owner of [r JUXs
property who builds or improves thereon,and who does such work himself or through his
own employ=,provided Out such improvements me not intended consisted forsake.If.
hawescgthcbuildingorimpmvcmcmissotdwi inomy uofcompkdon,mcawmr- FEBt Z 9005
builder will have the burden of proving that he did not build or improve for purpose of L .t
sure.). p
of me Sac.7 y,.B sines and convening with htmtaed contractors t. I W A ®�
;...as,00n`r
stmcL the pmjen(Sec.]614.Business and Professions Code:)The Conacmis Li. 1�1r:9� nl�e law dors not apply to an owner of property who Wilda or improve @emer,and,couacu for such prejecu with aconttnwr(s)licensed pursuant m the Contractor's
taw.
am exempt under S=. B&P C far this DamRKFR'SCOMPEN ATION D CLAR N1 hereby aRrm under penalty of perjury am of me fotkNmg dalarstione:
have mt0 will maintain a CeniBam of cement to self-insure for WmketsCcmpcn-
on.as no
for by Section 3700 of me labor Code,for me performanee of the
work for which this permit is issued.
❑1 ban and will maintain Worker's Compensation Insurance,u required by Section
3700 of the labor Code,for the perfm limo.of me work for which mix pc.I,is issmd.
My Worker's Compensation Inwnnce carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if the permit is return hundred dollars(SIM)
tr lCsa)
1 moody that in the performance of me work for which this permit is isucd.I shall not
employ any pcsson in any manner so as m become subject m the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiam of Exemption,you should
become subject to the Worker's Compensation previsions of the Leber Code,you must
'.JO foMwab comply with such provisions or this perm it shall be deemed revoked.
Z "M CONSTRUCTION LENDING AGENCY
r�.. Ibemby.Rirm that them is aco.do.kndingagemy far the pcif...ut
155 7 the work for which mu permit u isee
sued(S .3097,Civ.C.)
W QLcndcr's Name
:L. Lender's Address
U Q I certify that 1 have mad this application and sum mat the above information is
D. F' tamer.I agree to comply with all city and county om inan es and suite laws relating to
0 building contraction.and hereby rvmotlae representatives of this city to cuter upon the
Y' W abovomentiuned property for inspection purposes
t~0. (We)agree to save.indemnify and keep ha acmes the City of Cupertino against /
p3 liabilities,judgments,costs and expenses which may in any way same against said City
U in consequence of the granting of this permit /
^-� APPLICANT UNDERSTANDS AND WILL COMPLY WITH AINT Issued by: Date
SOURIE RFQULATIONS. n
(� I
si oI'APPIiaMCenuacmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOS E Type of Roof
Will the applicant or future building occupant store or handle haWcous mamnal
az defined by the Coconino Municipal Code,Chapter 9.12,and the Health and Safety
our,Sccdoa 25532(.)? a All roofs shall be inspected prior to any roofing material being installed.
0 Yea
Will the applicant or future building occupant use equipment or dedea which If a roof is installed without first obtaining an inspection,I agree to remove
Door h-ardour air Contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
Disvict? Y )IN.CS
I have mal the havardnua materials mquirementa under Chapter 6.95 of dm Califer.
u Fkalth& sty Cade.Suctions 25505.25533 and 25534.1 undersmM that ifdue Wilding
Jos not c ndy have a tenant Nat it ism taco ty m notify axis ant of the
myvimm wok maabemnpriormi aneepr.ce -Ram .Pan Signature of Applicant Date
m aamodzed as=est 1 DCamY All roof coverings to be Class "B" or better