00060160'
. CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT,
'
BUu.DwdADb49640 CULBERTSON
ITRMH NO.
-A
9WNERNNAPETER RABBITTAPPLICAI'10..
Ilk
D
fJNH:, _ -
- —
SANITARY NO. CONTROL NO.
m0 ZZ
ARCHITECT/ENGINEER: -_
- BUILDING PERMIT IN[ 0
RUE
BLDG ELECT - PLUMB MECH
LICENSED CONTRACI ORS DECLARAI RON'Oh
of
Ihereby affirm that Iamlicenmdunder provisions of Chapter 9prommwchmg
WATER HEATER RE NVEMENT
,.., tt
with Section 7") of Divaon 3 of the Businessadprofessions CoJ and any license
us in lull force and effect.
'
z 6
License CI„ns Lic. p
Date
3 i y
_.Cor,bveuk
ARCHITF.C'I'S DECLARA'I'[ON
a°—, g
I understand my plum shall he used as public records
t
oil n
�it Sp O
-
d
L¢ Professional
OWNER BUILDER DECLARATION
„t
•
m
I h by affirin tht . I am exempt firon the Connector's I.LecTOC Lmw for the
- 4
t:z
'Bill gra.u, (Section70315"B:n . radP I..or C I'AYcly 'manly
it
aF❑
whtehrcl csit prnut a null p letlsh p ray S nmre.
n C3 es
p° t t. issuance. also acquires me applicant non such permit file a signed statement
-'hat
Sy. Ft Floor'Area
Val ux i
he d. licensed poememto[he pmveoon.othe Contractor sldreaseLOW (Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Pmfesslons Code)
,
-
mr Shut he is exempt merdiom and me busts for the alleged exemption. Nry violation
- ". __
of $cdinn 7031.5 by any npplicunt for it la'nnim nuM1lats the applicant to a civil penalty
of not mot man flee numbed dmmrs'rgstxn.
AP�?,'pOfTRFb001. 00
'
Occupancy Type
ID 1, as owner of She property, or my nnployees withsdagesmthcir sole compensation„
44.
will ne ,he work, ssi the swcwm is not intender or se Lmd for sale Ism, to an
Business and Professions Code: The Corot morns License Lad dues not apply 0 am
502 — F I NPJquiRldl11M�FNfns ENERGY
woes of pmpeny Who hnllJs nr imamves merenn, and who doesmch work himself
or
50E — GAS TEST'
mmagh hi, awn nuployeca. poolded mot said, inpmmre
vceau amal imtamdm or
'
Offered for sale. If, however, the budding or improvement Is sold within one year of
'
SO! FINAL PLUMBING '
completion, the owner-htelder will have the burden of proving that he did nol build or
-
imprwe f,r purpae of sale.l.
,
Ell, as owner of the propeny, am exclusively contracting with licensed contractors to
g ,
e 7 usa ro
re t (See Smile,, J P f Code:) ) C fire(,,,',d
emorrom th pr 1 I
Lice 1 f I to a f l I h IJ. mp, fi
" q
and who contractsfor suchmitNts with a conloselorts),ficimocd personal ithet
d
Cum t r. L e La
❑ 1 am exempt under Sec 11 & P C for tats mtan
-
Ow -Dom
WORKIRS COMPBNNHONDECI.ARAI'ION
I hereby affirm under penalty of perjury one of the Billowing Jedarations: _
_ �t • ,
Q
J 1 have and will maintain a Certificate of Consent as self-insam for Worker's
.—
Comacosmion; as provided for by Section 3800 of the [..her Code, for the
Ferformmme of the work for which this pmra(Is bored_
❑ 1 have and will maintain Worker's Compensation Insm.mec, as required by Section
-
3800 ol'the labor Code, for the performance of the -work for which this permit is
sued, My WaTmr`s Compensation Insurance carrier and Policy number arc:
r `
.
Gurnee policy Nu:
CER'TIFICA'TION Or EXHMIT'ION FROM WORKERS' -
, -
COMPENSA'1'IONiINSURANCE
(This section road not M completed if the Fermi, is for one hundred dollars
,
(51BOB or less.) -
I certify that in She performance of the work for which this permit is issued, 1
ut
shall nemploy any person In any ntmmer en as to her re subject to Oue Workers'
.. -
Coa,meatien Law, of California. Dutra
Applicant
NOTICETOAPPLICAN'E lL after making this Certificate of Esemptiom. you should
become subject to She Workers Campemmian provision, of me Labor Cale, you ntmu
QQ. O
forthwith comply with such provisions or this permit shall he deemed revoker.
-
,^� Coil
CONS I'RUCT10N LENDING AGENCY
,. _ •'
I miebyaffrm tha dlemi, a caramelimi londingngency for the perfomrace
.of the work for which this permit is issuer (Sec. 31147, Co. C.)
_
Ls,mR,'s Name
.. - .
Lender's Address
uQ
thv Infan Ra
3 PP t, t n is
uagre Ibai l inn,-st ill this a
W [�.
.,,itfms uy mrdiemhm
d 1,1
correct. agree cmrydy wuh all city nod county omatives (and ,tate laws or upog
So building uniom,andhembyaomurizemproses. representatives of this city mentor upon
errs Fe u ra p se:
She h t id p pude
-- .
fy
has
nif
(N)greet a indemnify keep le ss She Cly fCpeninost
1
Uy
said
liabilities, judgments, cot and expenses which y m any y a against: said
7�.
Cdr n consequence of [hegranting of thisa n.
y
-
L
Issuedb Date
SOURCEREGULTIONS.DSANDWILLCOMPLYWITHALLNONaOINT
SOURCE REGULATIONS �
Y' - -
Signature of Applicant/Cmnracror :Dae
Re400fs
HAZARDOUS MATERIALS DISCLOSURE
Will the appreanior future building oacuprn Wore m handle Kameda.,mated:]
Type of Roof
•
as ddined by the Cupertino Municipal Code, Ch tiamil.I2, and the Horth and Safety
Code, Section 25532(x)?
1�YC1 - °No
All roofs shall be inspected prior to any roofing mat&riIl being installed. ,
N511 the applicant or future building oecupantrAc equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
mit Innuendoes air atmanlnmms to defined by the Bay Amer Air Quality Management
dstrie^
all new materials for inspection. Applicant understands and will comply with
❑Ycs ❑Nn - -
-
`'all non-point source regulations.
1 hove read the hamnlous materials rcyuirements under Chapter 695 of the-
Cilifomiu Health&Safety Code, Sections 25505, 25533 and 25534. 1 understand thatif
thecurrently have a tenant. that it is my rortmarbility m notify She,
mems which must be met poor to i>sunnce of a Cenilicam of
occupant of She mHerr
leancyinim
Early
i n
'Signature of Applicant 'Date
'
'- _ All roof coverings to be Class `B" or better '
Owoerormidmfaedagea, Due