02100181 CITY OF CUPERTINo ?,R
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:-
Bm11)pf9ApgR11%DRYDEN AV CUPERTINO PLUMBING PERMIT NO 2100181
OW+QI Y&I$ STEPHEN G AND BARBARA A 10297 S DE ANZA BLV APPLICA'flpt5sy"Ty2002
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ONE: (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHI1TCTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR DECLARATION
C m p 1 hereby affirmthat 1 am licensed under pmvivions of Chapter 9(enmmcncing Job Description
WATER SERVICE
gu6 wiresection]IXMrynrUiviainn]oath,,oxinesssy�ProfessionsCode.andmyliccnuis
in full fnmc I freer ./—
'"gz Liccne Clax t 3�r' rt'
F �, Date cCoantractor
r' j ARCHITECTS DE ATI N
C 1 undersand my pfire,hall be used as b is..,to,
no6u
Licensed Professional
0< OWNERBUILDERDECLARATION
ay I hereby affirm that 1 am exempt from the Contractor',License Law fur the $1500i E OO following reason,(Becton 70.11.5.Business and Professions Code:Any city or county
X m i which requires a permit to ceiramel,altar,improve,demolish,or repair any structure
maiprior it)its issuance.also ascribes the applicant lm such Permit o rile a signedstatemenl
Z< that he is l iccned pursuant to the provisions of the Contractors License Law(Chapter 9 3A6fl151ddL�A&G Valuation
W�$ (commencing with Section Ifik,of Division 3 of the Business and Professions Codc)or
y 3_ that he u exempt therefrom and to basis for the alleged exemption.Any violation of
Section 7031.5 by any applic rat for a permit subjects be applicant to a civil Penalty of PN N Occupancy Type
ant mamthaa few hundred dollars(SSW). 202 - UNDERFLOOR P UMBING p y YP
❑ L as owner of the property,or my employees with wages az their sole compensation,
will do the work.and the nmctua is at intended or offered fob sale(Sec.7004,Business is
and Professions Code:The Contractor's License Law does not apply to an owner of 30 2 - TUB &. qL �ChOns
pmpr,ny who builds or improve Ihercon.and who does such work himself or through his
own cmployese,provided that such impmvemcrux we not intended or offered for sale.If, 502 — FINAL PLUMBING ENERGY
however,the building of improvement is sold within sew year of completion.the m owner- 506 — GAS TEST
builder will have the burden of proving that he did not build or improve for purpose of
sale') 507 - FINAL PLUMBING
❑1,as owner of the proper,am exclusively contacting with licensed contractors to
conmiusrrct the Project(Sea to
Business and Professions Code) po es Cher cin. nd
cense law docs not apply je an owner of Proper who builds or intpmsrs thcmon,and
who commas for such projects with a cnmrennr(s)licensed pursuant to the Contractor's
License law. /
❑lam exempt under Site ,B&PClnr this reason /
Owner Date Q
WORKER'S COMPENSATION DECLARATION O
1 hcrcby affirm under penally of perjury oar,of the following dedaations: O�
I have and will maintain a Certificate,of Covent to self insum for Worker'sCompcn-
anum,as provided for by Section 3781 of the labor Code,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by section
37611 of the labor Code,for the performance of the work for which this Permit is issued.
My Wnrkcr s Compensation let orm t carzicr and Pulic We art:
Carrier 9-C, �(/.UJ Pnc�r Nw''%/3�/ UA/�T� C!N
S6 CERTIFI ACAQ0F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7hlx seetioa need not be compleoul if the permit is Ba one hundred dollars(S Its))
r le s)
1 wimly that in the perfnrmanm of dic work for which this pmmit is issued.I shall not
employ any Person in any manner m as to Wcome subjecun the Workcur Camprinewh oo
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccniricam of Exemption,you should
become subject In the Worker's Compensation provisions of the labor Code,you must
OO forthwith comply with such provisions or this pebmilshall be deemed invoked.
z� CONSTRUCTION LENDING AGENCY
[--� l hcrchy affirm that there i.sa construction lending agency lot M performance of
Sr the work If which this Permit is issued(sce,3097.Civ.C.)
1 0 Lcndcr's Name
7 z Lender's Address
U Q 1 certify that 1 have read this application and sate that the above information is
(•' correct.1 agree to comply with all city and county ordinances and safe laws relating to
V building construction.and hereby authorise representatives of Nis city to enter upon the
above mentioned property for inspection purposes.
F 1 (We)agree to save,indemnify and keep harmless the Ciry of CuPeninc against
p) Iiahilitics,juJgmcnts. .ts anJ�xPcnscswhic ay in any wayaccrue against sail City �� ^/�
U z in cnnuyucncc f gams of thi i O`)�`
.. APPLICAN' D_ERS NDS U L COMPLY WITfI ALL NON-POINT Issued by: Date
SOURCE �/
arnppr.anvcnn Daa Re-roofs
HAZARD ERIALS DISCLOSURE Type of Roof
Will thee Cupertino
Municipal
one.Chapter
ser handle hazardous ntarenal
az JCBrcd by the CUPertine Municipal C,xls.Chafer 9.12,and the Health and Safely
,MBLGtde,section 25532(a)'t
❑vex Nr All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future holding oecupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
Fail hazardous air aonmmi na ni defined by the Bay Area Air Quality Management all new materials for inspection.
D'nria7
❑Yca No
Ihavemadthe bar dour arialsrc mek,Chapw66.95ofthcCalifnr-
niallcalth�SafetyCnM,Sation 5505 3andc 534.1undemandthmifiWouilding
doeren sura ha alcnan I tis ysibihtyme the occupant of the
mquiremcnta Ir-n r /m riattr of eaificalcnf p ex `y, Signature of Applicant Date
V �
Owner., umdag I Dale All roof coverings to be Class "B"or better
s