00080126 CITY OF CUPERTINO
BUILDING DIVISION . PERMIT CONTRACTOR INFORMATION:
BU:LDINGADDRESS'. ' - - PFRMIFNO.
\L I
OVNER'S NA .. .1 APPLICATION SUB DATE .
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BEY
PHONE: BILL HRKK i bUN - SANITARY N(l. _ N^• 1. '
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00 ARCIIIT17 ENGINEER: - RUILDlic IIiItMIT INT
cpp4s BLDG ELECT PLUMB MECH
G idG r - IJ ' I-1 Ct C7
LICENSED CONTRACTOR S DECLARATION ARATION
E uf lob DescriptionoS�c s
mwd S d TY)OltuDo,kion3111
he Baumv,,aud Prof e..tons C d torr nylicense,
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s to full force and effect.
0.U 'Dae.caasa conn WATER' HEATER
O.se 'Lute Lic.conN un -
tsS 3 a ,ARCHITECI"S DECLARAUON `
O 1 code¢umll niy plans sinall he.,ad as public records
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dO O Licensed Professional -
°' OWNER-RUILDER DECLARATION
u I hereby affirm chat 1 am exempt from the Conlmcmr'i License Law for the - r
Ic 3< fall g amson (Section 7031.5,Busawistand Processions Col Any city car count) _ ..
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which p ran tot I I, pr e,wancorith,inrp nY xtruencre
E�I pno, I...re,mod,t ppl' ,I suchmit to I!ce a signed fLLnc,l
chat he licensed pt to the provisions oftM1 C rl I License Law 1CIsom9 Sq. Ft. Floor Area - Valuation
(commencing with Seaton]000)of Division 3 of the Business and PoNsxa ns Cock)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation -I .
of Sectimt a than
ha 5 v any cured
If II for a pnnnic suhjea the uPplicnm ra no civil pcnaity
..tBoc,more mnir,fiva luudred ngllma t85t>n)-„ � � ' '.APN Number , .' OccupnnC -
C 1.nv ownerof cue Property,m my",do",vi,h wages as their sole com,nt,ndnn,
will do the work,and the structure is not intended or ofieml for sale(Sm.]Mi,
Business and Professions Code:The Contractor's License Law dims not apply.to an ' . R fired Inspections -
weer of property Who builds or improves thereon,and who does such work himself '
aced fa m,own mnpluyces. thildod that suchmpr ve,ment I,undare not initiated
ar 502 — FINAL NAL PLUMBING ENERGY
stated IFIc for Sulu If,however,the rovided ha impnrvcntenl ixeds within ane year of r
completion.Ile ouoeMwiWer will base the Italian elproving dot he did not build or 50B GAS TEST
improve for'r,ah"of sale.). - - . .
❑I,a,awnerarinepro,Nny.amrxrlusinelyeadnactingwdnlicensedcammcmm,n 507 — FINAL PLUMBING
davamsr the project Isco.9044.11 a,,and Prot ..air,Cod,:) The Conlrnmnr'x
Ii Law does it,apply m,an owner of prnp.ny was bit if d,,the u,r: -
.adno actuated,for such pmlecls with a contractors)amoved.p c m the
Cooldoeme,License Law.
❑I It,scratch underSm.
It&PCfor this reason - -�
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Own, Dale a ..
WORKER'S COMPENSATION 131[CLARA1ION ^
1 hereby affirm under penalty of Perjury one office following declarations: 0,^
V,
CI have and will n villein a Certlfeati of Consent m xe Labsure for Worker's r '
Comport nce o us provided for by Section 3]1111 0l' the Labor Cade, for the -
pere,rmanre or me nark R,r wmen this permit is iax,red. - .
O 1 have and will maintain Worker i Compensation In arame,as rcyuired by Section 1
37
ode,the UN"Code,for the performance of the work for which this permit is '
` lsxucd.My,Wnrcar's Compensntimt lmurande cmricr and Policy number aro: 1
Carrier: Policy Nn: '
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he con,pleterl if the permit is for ono hundred dollars. ..
($100)car less.) - -
1 certify that in the performance of the work for which this permit is issued,l ,
shall nm cmptoy any peat in any manner so as to become subject to the Worker' -
Cemtmnsaion Laws of Califomdr.(late a - -
NOfICB TO'APPLICANT.If,ider making this Certificate'of iN ntplita,y..,I...and r '
0 Q become subjectlo the Workers Compensation provisions of the IrMa Cada you must
t forthwith comply with such provisions or mis permit shall be deemed mvoked.
CONSTR(1C1'ION LENDING AGENCY
I herehy uflimr that there is Ifcimscmecioa landlny agency for the parf(I it e
of the work for which his permit Is Issued(Sec 3097,Civ.C.) a -
L Q Lender's Name
,7 :z Larder's Address -
C.7 I caddy thus 1 have read his npplicmian and sidle that the above information Is -
kT+ f~+ accreta.I agree to c flyw,In all city and rounq ordinatcek and y as laws relmltg -
0 O rabuilding I t and h ld tl pre olives ofIl 'tit.tioner upon
IM t J property f .ties P T'-
r� CO) liabilities,(W)agree c indemnify dkeep harml:.the City fC pen .gams, _
Cil in now,m a of the
d pe which may n any y gins,rid O�
Y NDS rg if this L ,APPLIl
SOURCANT E REGULATIONS.DS AND WILL COMPLY WITH ALL NON-POINT Issued Date '
SOURCP.REGULATIONS. s
Signature of ApphcaMCnnmcmr. - Data Re-roofs
I IAZARDOUS MATERIALS DISCLOSURE
Will the anl+br:nmurrat..hundiagaceupittmurcufhatllehxzmdom.roarlid Type of Roof
as defined by the Cu icnino Municipal Cod,Chaplet 9.12,and the Health and Snfcly -
Code,Section 25532(p'!
°Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
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Will theapplicanlefhandle b dia,meopmnts-a hyaremnrdevim,which If a roof is installed without first obtainingan inspection, I agree to remove
emit hia"ohns air canwnnnantsassdefined by the nay Are.Air Quality Manngnmcnl P g
Dialrirf! all new materials for inspection. Applicant.understands and will comply with
❑rex °"" - all icon-point source regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of the
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can Into to Health&Safety Code,Sections 25505.25533 and 25534.l undersumd thin
if Om bah lding dims noiaurretdy have a tenant,thin it is my mspuniibil'try to nataly the
acceptant of die rears rennanis which may be ma priorto issmmcc of a Cantil te of
o"t"°a`y.' Signature of Applicant -Date
Owaermauthmimda,to - D.te All roof co4erings to be Class "B" or better
OFFICE _