01090083 CI]BUILDINGDVSONO
IIINPERMIT CONTRACTOR INFORMATION: ..
,
BUILDING ADDRESS: i PERMIT NO. -
1142 DERBYSHIRE DR CUPERTINO PLUMBING 01090083
OWNCR'5 NAME: APPLICATION SUB DATE
AMINE KLECHFE 10297 S DE ANZA BLV 09/20/2001
HONE: - SANITARY NO. CONTROL NO.
(408) 253-0618
O O ARCUrIECT/ENGINEER: BUILDING PERMIT INFO
m G BLDG ELECT PLUMB MECH
u =:I I= L_j I=_1
s.ai
,p y hereby
LICENSED CONTRACTOR'S DECLARATION Job Description
)y h Ihon 7000)of Nmin under sionsof Chopin9(commencing' P
an Nil force rD Division news andProfeaamnscaaaanamyb«nse' REPIPE, WATER SERVICE, &
o�u Licanu Class
j Ne.g d WATER HEATER.
Date a CDnas "
13 t�tn �7—1 ARCHITECT'S DLAR N
��.� ; „ '1 undersantl my plans shall he uud os public m<ords
3 i p O Licensed Professional -
' o OWNER-BUILDER DECLARATION
m 1 hereby ffin that 1 exempt tram the Contractor's Licanu Law for the.
followng (Section 7031.5,Business and Profession Cod Any city or county
��O wh q 'res a permit to construct.alter,improve,demolish, p tiny smacture-
.$ ..pq
thin he' 1 ensM pursu>m to Ne proisiom of the Contractor L n V IChapt 9 ,p ta, S t FIOOr'Areat 3 1 j ❑atlOn
(<om e g ithS cutin 7")of Dinsmnlaf the Business and Profess ora Cade) ,1,PL A L,fYf9� s h\ 1 t5?. sur.a : .' 1
or that he re exempt therefrom and the basis for the alleged caemptioa.Any violation - s
of Section 703 PS by any applicant for a permit subject,the applicant to a civil Penalty',
of not mom than five hundred dollars(1500). _ umber Occupancy Type
❑I;ss owner of the properly,or my employees with wages as their sole compensation; 1 nA _ SEWER WATER I
will do the work,and the structure is not intended or aRerea(or sale(Sec.7094,'
Business and Pnifessions Code:The Convector's License law does not apply to an' 2 02 - UNDERFLC10WiiRd U YI$nM "
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.prodrc
ved that such improvements anot intended or, 3 01 — ROUGH PLUMBING
orcered for sale.If,however the Wilding - . .. .._... _. _.
or improvement is cold within one
ar or
completion,the ownervbuilder will have the WNcn of proving tMt he did not build or 302 - TUB & OR SHOWER)' � ' - •.
implore for purpose of sale.). 502 - FINAL PLUMBING ENERGY
1. .. . ( ., . .. ..-. 506 - GAS TEST
❑1 whet tpropeny,am Business
acontracting with lisa:)The C Fact m
iverrocon�on the does
projectIsco 7094,owner and Prry who a ills or The comrcomr s 507 — FINAL PLUMBING I
and wh Law docs nm apply man owner of property who builds seimprovesn to the and vectors License
for such projects with a connotations)licensed purtuam m Ne,
Convectors License law.
pt
❑I ora exemunder Scc. B&PCime this moron' 1 '• _, ,t '
'Data
ER' C
WORKS COMPENSATION DECLARATION
FINALE
I hereby affirm under penalty of pe,in,one of the following declarations: 't p
❑ I have and will innimisin a Camficare of m sme 1Commit selGinfor Worker's OCT 7 2001
1 _ Compensation, as provided for by Section 3700 of the Labor Code, for the
perfomunce of the work for which Nix permit is issued. ,
13 T h and will;aiiiii.im Workers Compensation l suraince as required by,Secuon
3700 f the Labor Code for the perform of the work f h¢h N s permit rs
"sued.A1y-Workefs Camps t Insurance cwne'end Pol cy bar arc:" I�D'��
�- CERTIFICATION OF
Melvin
L ,,•w \
Omer COMPENS elvi {1 tai l i5 v t P 1.1�J C t i A ,P s yM
t G,(C:)) 1 t
FXEMPf10N FROM WORKERS,
ATION LNSURANCE-t
` (This section need not Ee c6mpierea if the permit is For one hundred dollen ' I
(5100)ar lay.)
r 's _... . . .... ....
fy,1 of perform o. f the a i for which u pe mi t ta sued I '- '• ' " "Compensation
II t employ any poison m any manna ao ns to becbme subject m the Wnrkeis r'•" '
Compen Applicant' ori Lews of California.Date "
NOTTCE . making Won.You should
- . . -.. . ..
Nommi in TO APPLICANT Worker's
offertaparethis Carl Cram of - -
Z becomeh minpm the surkds Compemzthis famnss shad)
due Labor Codayou must
forth uh c ply'with ch pro Isiom o this pertnit shell bed mW rtvoked. '
"CONSTRUCTION LENDING AGENCY r -
' Ifterabyraffiran Nat there Is a constmction larding agency for the perm
rfoance
Lard Address •h N s pc t ixsdN(See J097,Civ.CJ -
r7rZ
o(N ork fm hie
Lend N me
C.1 1 cenlfy Nat 1 lave nod this application d atom Nut theabove information is
Cir:[� <orrcn.I agree an comply with all city and county ordinances and sum laws relating
�'V m Wilding concoction,and hdcby authone,representatives ofthis city to enter upon
y tg) the above-mcmioned properly for inspection purpous;
;CalifilarriO
(W)agree io sae ad mniry dna keep harmless the C ty f Cuperiino against
ab Iwo judgencs,cost d penes h h y in any ay accm gainst said
ity t s (h grantingofNts pe tPPI C N R6 ANDS AND WILL COMPLY WITH ALL NON POINTOUR o Issued by: Date
ignal r. fApplican acmr ' '- "' '- Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE "' 'I'' Type of Roofdefined%the Cuperlino Municipal Code,Chapter 9.12,and the Health and Safety We SAY n25532() s.O No. - a ; av aAllroofs shall,be inspected.prior,to.any roofing.material being installed. .
WOlthe applicant orfutare &filled aseby the out use BayAequ pm nt or uality evices M..,, tIf a roof is installed without first obtainin an ins eetidn',I a ree to'remove
ranheaardoui air comaminanu m defined by Ne Bey Area Air QuJiry Management g p g""°" all new materials for inspection. Applicantunderstands and will comply with❑Yes ❑No al] non-point source regulations.
I'he "rcod'tha hoond s alteeials requ rements mde Chapmr 6.95 of the Health&Sar ty Code.Sections 25505,25533 and 25534.1 understand Nat
Oce on g Y my responsibility to notify the -
issuance of a Cerlibcme or
i the Wilding does not cu tl have alenant that it
tier o rcgmrcmenm,wh ch must be mel pnono
Zil_iv( - Signature.of Applicant Date_
owno or.athorl Date All roof coverings to be Class "B"or better
OFFICE - .. .._ .. . .