01070073 Y OF
CIBUILDING nrvEasiONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
7500 DUMAS DR BUDGET PLUMBING 01070073
o3vrrEg_s NpYM�N C ET AL 28695 ROANOKE ST A07cf 17 1001
7�Z
HHONNEU SANITARY NO. CONTROL NO.
(510) 303-7847
RCH ITECfBNGINEER: B CTDING PERMIT INFO
BLDG ELEC[ PLUMB MECH
f- L__I T=l CI
LICENSED CONTRACT'OR'S DECLARATION Job Descri tion
oI hereby affirm Nat lam liccnsedumlcrpmvisimuofChapler9(commereing WATER HEATER REPLACEMENT.
with Section7")of Division 3 of the Business and Profusions Code,and my licenses in full force and effect.
License Class Lic,a Dam Contractor
ARCHITECT'S DECLARATION
C E:0 g 1 understand on,plans shall be,used as public records
v�
pc Licensed Professional
'u
OWNER-BUILDER DECLARATION 5 1 hereby,(Sent Nat I win n exempt from the Conmr,Ca :A License Law roe the $550
3C whichiremoon.(Section Ilosr t.othe.imp improve.
at AnYCity n itwnty
ce e which require.a permit re nmstmct.alter,nt for such
demolish.m repast any souaum
pat heor Wissivounce,also eniedpnumn to the prevision of for euchperminm file vsigned
aw(Chptstatement
. - - - al -
thothais,lingwitpSetio 17000)provisions Division the Comluemrs,ad Ti laodon,Code)
or
A, 3rCss n[Jr r•171.a. A� I t - Valuation
(c that
ingwiN Section Y0001otebasonlofine Buidexepion.Any
Code)
or Shat Section
is 3 LS by
Iany applicant
and the basis for the alleged ekampnt 10 Any violationof '
..than
n five
any aimed and(or$500)Permit subjects She applicant a civil pewlty 5 02A VT rftL PLUMB IN ENERGYO P y Type
Orionof not more Nan five hundred dpll:us(E500). P-N CCn aRC e
❑Larerofthe property,or my employees with wages as their sole compensation, 506 - GAS TEST
will do the work,-and the-9tracture is not intended or offered for sale(See.]BN: 507 — FINAL PI I.�r��JJ"PISpeChOI15
Bmiress'and Professions Code:The Contractor's License law does an,apply to an
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.providedWilding
that such improvements mems are not intended or
'
offered for sale owner-Wilder
the buildinge improvement n sold within and ild�of
r
completion,for Be owner-builder will have the burden of proving Net he did not Wild or
improve for purpose of sole.). `
Ql.0owner°(the property,am(Sm.74A. uiniss and contracting with conrracmtsto
' conswn the project(Sm.]044.owner of and arty who
CW,:I The Contractor s
Licenselaw Jas not apply to on owner of property who bu Ids or imp t -
and, ho contracts for inch.pm3ec s w th a commutons)licensed purwam m
R,Corrientes License Low. t
❑lam esempi under Sec .B&PCfonhs XPI
Owner � Date
WORKER'S COMPENSATION DECLARATION :Q7
I hereby mifrn under penalty of perjury one of the following declartioni' .w...
° 1 have and will-maintain a Ceniacme of Consentto self-insure for Worker'
_ Compensation, as provided for by Section 37M of the Labor Code, for the
performance°f the work for which this,permit is issued.
°1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of She Labor Code,for the performance of She work for which this permit is
issued My Workersoatpenmn nsumncc carrier and and Policy number e„r:
_ ....s..._.. ..,,,-.._... ... .. .. .. _.,.�........
Cniric"r:' s' L-! ell. u"Policy No.:' . .•t-i, t:', s 'ni't Jl�t,f \ r•� :,.
CERTIFICATIONOFEXEMPION FROM WORodR$'�' - - • s,
.:,. ,
COMPENSATION INSURANCE"
(This section need not W Completed if the permit is for one hundred dollar
($100)or less.)
1 certify that in the performance or She work for which this permit is ismed,I - -- -
shall not employ any person in any manner so as to become subject to the Workers
Compensation laws of California.
Applicant_ - '- '
NOTICE TO APPLICANT.It.a(ter making this Certificate of Exemption.you should
become subject to the Workers Compensation provisions of Nm
e Labor Code,you ust
O forthwith comply with such provisions or this permit shall be deemed not ke 1.
E" CA •' ". `°CONSTRUCTION LENDING AGENCY
> 1 hereby offiSm that there is a Construction lending agency for She perlobxxb a
Qof the Lenders soNmfor ne which this pemtit is issued(Sec.3N7,Civ.C.)
Z Lender's Address
t> Q 1 certify Not I have with Shis application and ordinances
a above maws r hat
fz F correct.1 agree to comply whM1 hollereby
city and county ordinances and state laws«Latingto \
the
mentioned
,nd hfori suection upossenmlives Mthis city to inter upon _
the vbovcmentine 1.pmpeny for and on purposes,
(.r' S (We)agreetosave.ostandepenseskeep which
mayinthewayaof Cupcniaiagainst
d
t/] liabilities,judgments,cost and expenses which may in any way I I against said
V•z City in con.m UND of the granting of Nis permit.
^ SOURCE REGULATIONS.D$'ANDWILLCOMPLYWITHALLNON`POINT [ssuedb Date
SOURCE REGULATIONS. - Y
Signature of AlplicanuCmarbchr Date- Re-roofs
,.
HAZARDOUS MATERIALS DISCLOSURE
s Will the applicant Cupertino
or future bonding occupant start or handle Health
sd Sleety Type of Roof,
..... ..... .
C defined ionbyltheZ5Cupertino Municipal Cale,Chapter 9.12.and the N<a1N and Safety
Code El on 2553'_(x) ; (.• (. 's , .:
°v s:� °No '' I' . . All roofs shall be inspected prior.to any.roofIng material being.ins[alled.. _-
Will the applicant or future building occupant use arimparem or devices which If a roof is insialled'without first obtaining an inspection, I'agreeto remove
emit hazardous air mmandmanls as defined by Ne Bay Arm Air Quality Management
Dinrict� all new materials for inspection., Applicant understands and will_comply with
ClYes °No all non-point source regulations.
1 have wad the hazardous materials requirements under Chapter 6,95 of the
California Health&Safety Code.SICtinns 25505.25533 and 25534.1 undemmad that
if the building does not currently have n tenant,that it is my responsibility to notify the -
occupant of the requiremen¢which most be met prior to issuance of a Certiri.a of
° ap'°`y Signature of Applicant Date _
Owner or authonzed agent Date All roof coverings to be Class"B"or better
OFFICE -