01040138 c1 of CUPERTINO
BUILDING
M CONTRACTOR INFORMATION: -
uutuNc otvtSIOstoN � � PERMIT '
a RUILDINGADDRISS: - PERMIT NO.
1171104 CRESCENT 01.040138 '
OWNER'S NAME. - _ APPLICATION SUIS DATE
04/':5/2001.' .
PHONE: - - SANITARYNO. CONTROL NO.
C Z ARCH]I EC'VENGINEER:' _ BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH_
a
Z S y z - LICEhat I a CONTRACTOR'S DECLARATION { Job Description
O Z_O ,li FXX))of that I um of it,B under pual[I m of Cntpsr9(commencing p
is or fa,iorecand oflea,. i,m3o[Ihe Nu,ineswmJ Pml'csxinns C,tlu.and myllecnse
zf ksitm Class ,I,eeBhnt. INSTALL NEW, GAS LINE BETWEEN MAIN AT.
as a Liansc class Lie.x - ,-. -
O a O Date Contrvaor
'soy ARCHITECT-s DECLARATION `?. POOL. PAD/GASHEATER
S1 undcodand my plan.Shull bn used us public raves
Licensed Professional '
°.]o OWNER-BUILDER s Ill CI ARAI'lI1N .�/ _
I h by off!.don I el pl f m 0 Contractor
I 1 I'or the ,
f-Z G (nil b Iicci )(D LS B c nd I r x Cad Any city ,may - 4
F O wh n requires; permit t :I t Ise -improve,de h Fl Y structure V
3� pool I '' ab y the pili tl hl Ilk) :b dalenenl'
mutes sedpanamt thept, fn e t out 1 (Chapter 9 S Ft. Floor Area Q% alua[ion
(commencing thSeet 711(10) fD u 1 of the Business IProfession,Codi �. .
or that he is exculd therefirom and the hasis for the alleged exemption.Any violation
lotion
of Seel...7031.5 by any a,fi,ala ser n'mat'adjeel lle applieml It, civil penally
nfmm�e,than ivehundrddollars l$500f - - APN Number - Occupancy TI pg1
°I,an owner of flue property,or my employees with wages IIx their sole compensation,
will do the work,fall the smuenru ix n1,1 Intended nr offered to,sale(Sec.71114,
Business and Professions Gyle:The Contmcmr:s License Law does,not apply to an 3261,7028e,06ed Inspections
owner of ppery, on
Who milds or improves there ,and who does such work himself ..
ro
r through his own employees,provided that.such Impmvcomnts arc not intended or -
offered for nate. L however,the building or oupevement is sold wl11do one year of -
comple0oo.the owner.Wilde,will have the Wadgnmfpm,in,that hediddo,build.1 106 — SEWER B• WATER.
improve ,pwpose of sale.).
/Jb 202 — 'LINDERFL..00R PLUMBING
'
ILLYusnwncrot'the proneny.,,,,exemsively em ma.fi,win,licensed ennlraclms to -
oaslmat Ihe project(see•.n s a„e Praressmn.C,.le:1 The Card amors 301 — ROUGH PLUMBING
License Law does not a ly r of pmpcny who builds or improves thereon,
ane < It: res 1 n j wx who a„mracmdxl l 1 p ..,m m,Ne .
caner r:1 s , 302 — TUB & OR SHOWER ,
exnp ' cr misreaan 502 FINAL PLUMBING _ENERGY
X / c/ i. — GAS TEST
own / 'o`(< IR oMrItNSATIun<>FcZ� Tlor�i � 507 — FINAL PLUMBING' -
1 nereb5'Minn under penaky est perjury one of Ihe following dcabaadnoso .r .. '
° 1 have and will mdmhnn a Ciaudiente of Consent a sdLln,uo,*for Worked,
Compensation, as provided (o, by Section 37W at tire Labor.Codi far the •'
perfonnunce of the work far which this panni,ix issued. -
a .
°1 halt,and will maimed Worker',Contpcnsulin iInsurance,as required by Section J
37M of the labor Code,far Ihe performance of he work for which this permit is -
issud.My Worker's Compensation Insurance carrier and policy number are: - '
Carrie' ` Policy Nn.: -
CERI'IFICA'f1ON OF E IEMPLI(IN FROMINSURANCE WORKIikS'
COMPENSATION INSURANCIi
Crhis section need not he ronlpoed If the permit is for one hundred dolWn - s
(Sl BID Lir less.) _
1 caddy that in the ,art..a ee of O,e work for which thin Pcraiil Is issued,I -
,hall nal employ any person in any manner so as to become subject to the Workers'
Compensation Wws of California.Dale -
AppGem,I
NOTICE TO APPLICANT:II,afar necking this C'om'a,of Exemption,you should
1,omda subjecno the Workers Cmnpnsa
cmo pmemons of the Labor Code.you most
'0 O Forthwith comply with such provisions or this Fannie shallnedeemedrevoked-
^ V� - CONST RUC I'ION LENDING AGENCY - y
a7 I hemby Mira that there is f onnstruction lending ngcncy for Inc p,,dame, - - -
of the work far which this pcnnit k issued(See 3097.Co.C.I.
Q Lender',Name -
Leader'sAOdress - -- '
V 0 1 certify Ina,I have read this application and state that the aba Ic information is
W F.. coma.I agree to comply with all city and county ordinances and state laws relating
0 [) to building umvb'adlon,and larch;un@„rim rcpresonmllvawf this city to cmc.upon
;a, Fel 'Ne ah - mentioned roup)t5 m,in fe do
[r 0.
(We)agree to sae.indenchily andkeep hra le.the City of Cupemeo against
to liabi I FICS,Judgments,c , d eviverses whith may in any way arose,ago ns said '
V Z City'in unwalaan.aof ll, ....itg,rlhis( roil I
APPLICAW UNDERSTANDS AND WILL COMPLY WITH ALL NON POIM'
SOURCE REGULATIONS. Issued by: , Date
Signature of Applia:mUConll actor Data - -Re-roofs' - -
HAZARDOUS MATERIALS DISCLOSURE _ 'Will Be, pplicam or future Wilding ceeupanl xoom or kin ffit,W:ud.mi rmt rill Type of Roof '
as defend by the Calsomno Municipal Code,Chapter 9.12,and the Health and Safety '
Com.Seclion
❑Yes '°w, - All roofs shall be inspected priorrto'any roofing material being installed.
win mu Ira and nrmtmm�wld agnecupolnius,equipmmnordevhavwhich If a roof is installed without first obtaining an inspection, I,agree to remove'
,not hv..chi s civ cnmmoirmtx.,defined by the flay At,,,Air Quality Management
• District^ all new materials for inspection. Applicant understands and will comply with
°Yes 11 No all non-point source regulations.
I have end the haaankmI nunerials requiemems under Chapter 6.95 of(he , - -
California Health B Safety Code,Sections 25505,25533 and 25534.1 undemmnd'he,
if the building docs not currently have a tenant,Bad i,is my mspansibility to rally the -
l'u,ont of the tegairemend which mnu be sen pri "la ce of'a Cemllif -
oaupan.y, or m cme o
Signature of Applicant Date
ownerntauto orl...l agent., Date _ � All roof coverings to be Class "H”or better
OFFICE