05020050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMAPON
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BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT N00
5020050
OW NER'S NAME: PERMIT ISSUE DATE
NO.
ONE: SANITARY CONTROL NO.
(r' 0) 376-4816
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
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!!0,! Z LICENSED CONTRACTORS DECLARATION
Job Description
F 1 ion? ).f snob I am licensedOBio under previsions OfChapterCode, i(commencing P
`uf with Scnian]IXgD of Division Sof NC Businessand Profcuiuna Cade.and my license is
^ Nin full force and effic
LIZ Lima cars H/ Lk.g 7 90 REPLACE WATER HEATER
n^O Dae con 1411 toe...
EE A shall
used
DECLARATION
C U I undersmnJ my plans shall be used u public rtcnrds �Y]
3LLG Licensed Professional
`05 OWNER-BUILDER DECLARATION Y/
<f 1 Wmby affirm Nal 1 am exempt from the Canuaaor's License law for the Q
00 following mason.(Section 7031.5,Business and Prefessiom Code:Any city or county sU�
$ which¢quires a permit a consuuct,abet,impnsve,demolish,or repair any scone. V
Fly prior to its issuance.also requites the applicant for such pemiuo file a signed statement
< that he is licensed pursuant to the provision of the Comracmri License Law(Chapter 9 Sq.FL Floor Area Valuation
¢tea (commencing with Section 7")of Division 3 of NC Business and Pmfruium Code)or
OuR S that he is exempt themfmm and the basis for the alleged cwnption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 1A93 P.Ntk0el0 0 OType
.at tome man five hundred dollars 450d).. Occupancy Y YP
❑1,As Owner of the propmy,or my employees with wages as their sole compensation.
will do the work and the swmure is our imenticd or alfcred far sale(Sce.7044,Buttner
and Profen toes Code:The Contractors Limine Law does not apply to an owner of Required Inspections
progeny who builds or improves thereon,end who does such work himself Or through his
Own employees,pmvidcd that such improvements are not intended oroRered forsale.If,
b..,,Ne building or improvement is sold within am year of completion.the owner-
Wildcr will have de When of proving that M did not build or impmse far purpose of
sale.).
❑1,as owner of the propeny,am exclusively convecting with licensed conuxtors to
consumes be project(Sec.7W4,Business and Profeuiom Code:)The Contractors Li-
cense law does not apply to so owner of property who Wilds or improvm thereon,and
who conmcu for such pajeeu with a eonmctor(s)licensed pursuant to the Contractor's
Lirene Law.
❑I am exempt under Sec. ,B&P C for this msson
Owncr Dae
WORKER'S COMPENSATION DECLARATION
1 hereby arm under penalty of perjury ore of the following declarations:
I have and will maintain a Cenircate of Consent o coo-insum far Worker's Compen-
sation,As provided for by Section 3700 of the labor Code.for the performance of the
work far which Its permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,az required by Section
17W of the labor Code,for the performance of the wart for which this permit is issued.
My Workeh Compensm/iL•n lnsut/pp)ee artier and Policy number am:
Came[ TATE her.orr' Policy No.: /6 53714- _ .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sCedi.need nut W tomplced if the Permit Is retreat,hundred dollars(Strait
or less.)
I certify Out in the performance of the work for which this permit is issued.I shall at
employ any person in any mortician as us become subject to the Workeri Compcnution
Laws of California Dae
Applicant
NOTICE TO APPLICANT:If,refer making this Cenific6e of Exemption,you should
became subject to the Worker's Compensation previsions of thn labor Cade,you must
.,2, forthwith comply with such provisions or this permit shall be dmmcd mvoked.
z CONSTRUCTION LENDING AGENCY
I hereby arms that them is a concoction lending[� y g agency fnr the perfurma c of
C1, the work fur which this permit is issued(Sec.3097,Civ.CJ
157 0 Lender's Name
D' Lender's Adtlmu
V U 1 comfy&.11 have mad this curimui pr and sue mat the Above information ix
U C) correct.1 gree m comply with all city and county ordinances the,
sue taws relating m
17 V above-geononcalpgand hereby euNodmmolues. Lives of this city in enter upon the
r W ahovcmemionc0 progeny for inspection purposes
F gy (we)agree to save,indemnity and it.,harmless Ile City of Cupertino against
f/) Iiabilidu,judgmcnu,cmuandeage�mwhichmayinanywayamrocagaint.uid City —�
U in consequence of the granting alibis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ULA S. /
n7 rofl,1 n ti� Re-roofs
Signature of Applream/COnmctor 'Dae
. HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant marc or handle hazardous masted
A,outlined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,S❑ n25513(a)?yes 9K.— All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant are,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harsrdous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad the hanrdlwsmaleriabs requirements under Chaper6.95 of Ne Califon
nia Hcalua&Safcy 5(15.355]3 and 35534.1 undcrsenou thatifNc Wilding
doa trot cure ave a womt,Nat ¢my msponihility a nrdly tM Occupant of Ne
mquimmcn w'ch mmtbemn psi isibe mafacomr, Ora apancy. Signature Of Applicant Date
Owner m,amOrivcd
O Z�1: 1 DVex agent Va. I All roof coverings to be Class"B"or better
1
CITY OF CUPERTINO5-
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WATER HEATER 0
CUPEI�TINO PERMIT APPLICATION FORM
Date:
Build in Address:
Owner's
GU
Contractor: is se #:
G E 9 90
Contact: Pho e #:
Applicant/Contractor: S
Building Permit Info:
Bld Elect um Mech
Job Description: aTE.t
esidenttal: Commercial:
Sq. t. loor Area: $/Sq.Ft.:
Architect/Engineer: Valuations
Type of Construction: h / Occupancy Group:
Qty. if V v
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
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