02100011CITY OF
r
IDINGIIVISINPERMIT
CONRACTOR N OMATION '.
Bu112fTV2WFSdCREEKSIDE CT
CUPERTINO PLUMBING
PERMITN02100011
OWI OSDEOTIS E AND KATHLEEN C
10297 S DE ANZA BLV
APPLICATITVYBMTg2002
IIONE
(408)253-0618
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINCER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB0 MECfI
0 0 0
LICENSED CONTRACTOR'S DECLARATION
lihereby aRrmmnsom3Bche previ.[ion.rrtcham.
hh❑
COPPER REPIPE/'RWT2ffi94MTER
B ovinia
wish Section ]1NMB of Division 3 of me BusincmunJ Pnsfcs[ions CuJc. and my limnu is
add my
in full force and effect GZyQGS
Livens, class G3 Lie..
WATER SERVICE
Dale mriclnr! lei
ARCHI CI'SVl) RAVEN
1 under h J Y plu sk .benaero
I-ieem"d p nal
OWNER -BUILD ECC
1 hereby Ifrm that I am exempt Go a Conlrannr's LianW Law Irr the
Contractor's
following rectum. (Second 7031.5. Business and Professions Core: Any city Or county
which ¢quires a permit In emalmel, alter, improve, demolish, or repair any structure
C, O O O
poor ser its issuance, also requires the applicant bor such permit to lite a signed statement
that W is licensed pursuant to IN provisions of dic Corturactur's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section ]av)ofDivision 3othe Business and Professions Craft) in
32639061.00
that be is exempt therefrom and the basis for me alleged exemption. Any violation of
Snaion]031.5 by any applicant for a pc.i,subjecrs IN applicant m a civil penalty of
than five hundred delta. I$").
APN Number
Occupancy
Pane y Type
not mem
202 — UNDERFLOOR PLUMBING
1, as Owner Of the property, or my employms with wages as their We compensation.
will do tW work. and me stroctum is not intended or offered for We (Sa. 70,W, Bmim.•
38i ReusH NI
and Proressions Coder: The convectors Liuroc law does not apply to an owner of
502 - FINALMZU e f�liFRGY
property who builds orimproves memon, and who Jmssuch work himaelformrough his
ownemployccs. provided thalsuch imprommentsarenorintended monitored for sale. If,
507 - FINAL PLUMBING
however, lie building or improvement is sand within one year of completion. the owner -
builder will have the burden of proving ma he did not build or improve for puryo. of
j� (gbh
! p g)i
.1k).
l� YMi mesh T
❑ I, asr of me property, am exclusively contracting with licensed commercialm
c the
cnnstruaproject (See. ]OMI. Business and Priced.. Code:) The Codtraclor's Li.
cense law ams not apply to an owner of property who Wilds or improves demon, and
0 C T 2 9 20 02
who contacts for such pointers with a coram etor(s) licensed pursuant to the Contractors
License Law.
❑ I sum exempt under sec. ,B&PC for this moron
BUILDING
Date
WORKER'S COMPENSATION DECLARATION
1 hereby afore under penally of perjury one of the following declarations:
I have and will maintain a Certificate Of Coranno to self-imum for Worker'a Compen-
sation, as provided for by Section 37W of the labor Code, for the performance of the
work for which Unix permil is issued.
�,j I have and will maintain Worker's Compensation Insurance, as required by Section
37W of the fader Gale, for the performance of the wink fur which this Notions issued.
My Worker's Compensation Insurance carrier and Policy number art:
Camer.sTA--rIk- frLi- D Policy Nr.:9lZ2) VWITQ2Xi7
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal be completed if the permit is forene hundad dollars (16100)
Or less)
1 certify that in the performance of the work for which this Permit is issued, 1 shall not
employ any Pers any manner so a as beuomeaabjec, to the Workers' Compensation
Laws of California! Date
Applicant
NOTICE TO APPLICANT 11; after making this CeniGcal, df Exemption, you .mould
become subject to the Worker's Compensation privit.sons of the IaWr Corl you must
forthwith comply with such provisions or this Permit shall be Jcemed resulted.
CONSTRUCTION LENDING AGENCY
1 herby allure that mere is a comwetion ]ending agency for the performance of
the work for which this permi, is issued (Sec. 3197, Civ. C,)
L.cndm's Name
fender's Address
1 certify Nat I have read this application and state that the above infoma0on is
Correct. agree to comply with all city and county ordinances and cute laws winning
Willing ro, and hereby authon this
rposescntalivcs
l .
of city to cnlR upon me
e
mentioned rteimnifyan keep purposes,
p
abovee(we) agree to
(We) agree m Wve, indemnify and keep harmless me City of Cupertino against
/
��/�~
efwhich ayin any way acerae against said City
,aemnsed.9 rev the
in cnnscyuc cc the graining of Phi
fill
AP LIC T NUE STANDS D OMPLY WI LL NON -POINT
Issued by: Dale �� d
&�dRe-roofs
SOUR ULA NS.
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.61.
r
5 slur fApplicanUCuntra o Dam
LAZAR IA S DISCLOSURE
Type of Roof
Will me appnican, or firm building m<upam store or handle haallous maknal
as definefi by the Cupenino Municipal Gale. Chapter 9.12, and the Health and Safety
0 Yea No
All roofs shall be inspected prior to any roofing material being installed.
�Cram,sectsonn53z(ay
Wal me applicant or rent t building m tipanl use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
mil W,omux air contaminants 5s defined by the Bay Area Air Quality Management
Dlstdnyrr
all new materials for inspection.
p
Ycs
I have read thc nus n¢ualcr Chapter M95 ofth
Z!(505lsrtt 3sual haddix-
ray Cs aot.that , 3sporobls.Iundotify
doesnolUnp, dtWtiftMWilling
does no ( oily nn a tenant. Nm' respnnsibility.ln notify the rccupant of me
require, .1 hichn stncmrt, It" Worrell mirluracuparay
Signature of Applicant Date
All roof coverings to be Class "B” or better
o , D„t