02110023 CITY OF CUPEW11NO `_�_ ✓ y I' •• ""f h.ai
BUILDING DIVISION PEI 14CONTRACTOWINFORMATION
Ko,• tel. . Ai
BuE.1?l818%4L5FsDRYDEN AV CUPERTINO PLUMBING PERMITNf02110023
CyCC s'w7R1(3RY JOHN H AND MARILYN L 10297 S DE ANZA BLV APPLICAT1?_1vTL &q[y2002
Affill
orZONE: __T408 253-0618 SANITARY NO. // / CONTROL NO.
ARCUITECf/ENGINHER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
woo LICENSED CONTRACTOR'S DECLARATION O O O
.w G 1 Mreny altirm teal I am licensed under provisions of Chapter 9(commencing !Ob DOSCIIpt10n
R<a wldon)IXMpor Division 3nf activation]Professions Gyle, cal my license is WATER SERVICE
F D y in
IV ave and cffec rr��N�n
z o�,/,3 License Class ` Li,.x n ��uV
41
o�.,ZF,W talc�' �7 GrmPECLL
`r�_a _/ ALEMO
ARCIIITLl`4.�ar1!CLAR TION
�gaa ••—�,tundcrsmnJ my plans shall be used an public mcoNs NOV O 8 2��2
0 ac
3 a GLitt sed Prmcsaional
=ms ' OWNER BUILDER DECLARATION I
yet r<8 I hemby affirm that 1 1. exempt from the Contractors Cycle;
Licenu Lawl em the
BUILDING $1200
m S O o following reason.(Section)11}15.Business and Pmfcssions Code.:Any coy or,coumy �NG
w fLi' which rectors,a permit nI construct.Blur,improve,demolish,Or repair any structure
prior m its issuance.also restores the applicant lot such permit to rile a signed statement
thalncfslieened pursuant o the provision,of the Contractors License Law(Chaptcr9 Valuation
yFC (commencing with Section 7000)of Division 3 of the Bustyexsand Profeaions Ccal
i 3 that he is exempt therefrom and the basis for be alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil ppulty of PN-N (]CCU anC T
Toy mom mane enmarta umlar,faslxa �! 202 - UNDERFLOOR LUMBING Occupancy
Type
I,u owner of the propony,or my employees with wages as their sole comphpctio n,
will do for work.and the structure is not intended or offered for sale(Sec.7100,1;Business
and Professions CWc:The Contra is License Law docs not apply to an owner of 3 02 - TUB $c PvOUFf t1RAC(;UOn$
praperly who buildear improves hereon,and whodoessuch work himulfor through his tC bb WL°IC
own employees.ptov{ded that such impromments are not intended or offered forsxle.It, 502 — FINAL PLUMBING ENERGY
however.the building or improvement is sold within one year of completion,rho owner-
builder will have che burden of proving char he did not build or improve for paiiwse of 5 0 6 - GAS TES T
adi 'I 507 - FINAL PLUMBING
1,asr of the properly,am exclusively contracting with licensed contractors to
construct me project(Sec.7064.Business and Professions Code:)The Contractors U.
cerise Law does not apply In an owner of property who builds or improves human,and
who contracts for such projects with a Contractors,licensed pursuarn to the Contractors �
Lice
nu Law.
El am exempt under Sec. B is P C for dais reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
41 I hereby aRrm under penalty of perjury one of Be following declarations:
❑l have and will maintain a Certificate of Conant to self heart for worker'xCompen-
urion,as provided for by Section 901 of the UNIT Code.for the performance Of the
work for which this permit is issued.
❑I have and will maintain Worker's Cempensarion Insurance,as required by Section
3700.f be Labor Code.for me Nfinmmce of the work for which his permit is issued.
My Worker'a Compensation Insurance carrier and Policy number am:
c 1: Policy Nu.:7130/u,OlTDg2
CERTIFICATE OF E%EA FROM WORKERS' (gyp
COMPENS IT] URANCE
(This section need not he completed if the permit is Gu oneM1onJon tlnllars(Sigq
nr lcssJ
1 certify that in the performance of the work for which this permit is issued.1 Ihall not
employ any person in any manner so as to become subjecoo he WorkerCCompcmation
Laws of California.Data
Applicant I
NOTICE TO APPLICANT:II:after making his Certificate of Exemption'
ybo should
become subject m the Worker's Compensation provisions of the IaMn Code.'yrm must
0z forthwith comply with such provisions nr this permit shall be deemed revoked:
7—C)
CONSTRUCTION LENDING AGENCY
(•" I hereby affirm that there is a construction lending agency for the erfory ante of
he work for which this permit is issued lSce.3197,Civ.C.)
{al Q lender's Name
7 z Under',Address
V Q I certify hal I have read this application and some that the shove information is
fy (✓ correct.l agree to comply with all city and county ordinances and state laws retain,to
0 V building construction.and hereby authoree mprewntarivcx of dais City to enter upon the
r 4.1 above-mentioned property I'or Inspection purposes
(, y (We)agreeof Lir sax,indemnify and trop Icss the Ciry of Cupenim agaimr
V Imbilili ^,.Cne at C.P to o,hc ay in any way accrve against said City
Z
damn gra .,,if
APPLICA DER AN NO COMPLY WITH ALL NON POINT Issued by: Date
SOURC An N
ZV4 Re-roofs
/ IIAZmrDOU TE IS DISCLOSURE Ustc Type of Roof
III me applicanlrmcuPent stem or handle h..dous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Uealth and Safety
Cnde,so ion 25532(x)1 - All roofs shall be inspected prior to any roofing material being installed.
Ycs No
Wi11 me applicant IT sore building Occupant use equipment ordevbca which If a roof is installed without first obtaining an inspection, [agree to remove
mit hazardous air sentare inams as defincdby the Bay Arca Air Quel ity M dn6gemenl all new materials for Inspection.
District?
❑Ycs NO
I have :ad M1ara mem als my n t nosunderChapar6.95offoCalifor-
niaHcaldaffi 'cry'ales. tions2 15.255 n 255U.lomkrsonI rho if die building
Jrrs no cu ml Ea nr,h m r meihilit r y the rcctpanIII me
mquimmen w sec' eco Cc. nt ampaney,l Signature of Applicant I Dale
Dole
D All roof coverings to be Class "B"or better
O 'rte r 's age DI I I