NO PERMIT NUMBER CITY
OF c DPESSIONNO CONTRACTOR INFORMATION: PERMIT NO.
PERMIT
BUILDING ADDRESS: NO. M1KNf@MbffrTALDKn
DR
owN�
ii �, N,m6Y) T LIA� O"tW( ff ,�,}L ytJiJ(1-1 �11V11`^/y1/,•I.µIC''J�
QOU DN/C G°
ARCHITECT/F.NGINEER - � pULDING PERh/1T INFO
Z O y "-) LICENSED CONTRACT'OR'S DECLARATION '
L hereby aRren Nat 1 am licensed under provisions of Chapter 9 commencin
O Z-o ( $ Job Description
P4C withS«tncoari 0)ofDivisi Sof the Bueineuand Prof yCodc, liana is
ay Liters, "-55 G " DI RE—PIPE
d0 U I-¢en6t teed k� L�/�
yy Deu Convector n /1 1 )_'�n I� 1 gP/v1y/1/J�n'
O As"I W use DECLARATION W Y 1ty{vq` (�t�(v/
v�y, 1 understand my Plans shall W used u Public records ,
6f
dCoo Limited ProfeWmal -
u�='y
OWNER-BUILDER DECLARATION -
C?Q I hereby sfErm that 1 am exempt from she Convectors License Law for the '
C following mason.(Section 7031.5,Business and Pmkviom Cade:Any city or county '
m
which RgWleane.sheretumsthealUc.improve,tforsuhperittsh,nrrasigany tWRent S Ft. Floor Area
pdonolmlensedpulsom'.the thovisiosoffor Ceh Permit NfileeaLw(atabmem LI' $2000
thatmmehe ri ting i pursuance the of Disfonaof Ne eBusinesa License Won.Codtv9
(commencing with Samson]00p)of Division 3 ofthe Business and AvfeeaionaCnde)or
that he is exempt therefrom and the Buis for the alleged exemption.Any violation of a�AYl Np er Occupaficy Type
Section]031.5 by any applicant for a parent, the applicam to a civil penalty of J a
not mem than rove hundred dollars($500).
❑I,as owner ofthe property,or my employees with wages an their sole compensation, Requirea Inspections
will do Ne work,std tiw svucture is nm imrnded proffered fm eele(Sec.]664,Budrrtts
and Pmfmdons Cede:The Concactori Li«nse Law it..nm apply to ae cant,of
property who buildsor improv.Mrt
eosu
n.and who does ch work himself or Nmugh 202 — UNDERFLOOR PLUMBING
his own<mployeet,provided Nat such improvements are not imendal m oRered for 3Q t Rt�-/t�(!�G UMR I '
'We.ILhowever.dIhave dingorau of prism IssoldI within me Wildon of improve for
.7iia� ENERGY
ewner-builder will have Nc burden of proving that he did not Wild or improve for par- : F L . .
pose of sale.).
1,as owner of the property,am exclusively convening with licensed contractors N Q FI AL PLU I NG
consumer the project(Sm.7004,Business and Professions Code:)TW Contnctob Li-
nts taw does not apply to an owner of property who Wilds or improves demon,and
who convicts for such projeche with a contmemds)licensed pursuant o the Convacmrt
License Law. -
❑l Wmtxemptunder S«. - .B&P C for this,ewon
Owner Dam �O .
WORKER'S COMPENSATION DECIARKRON •�
Ihereby affirmend«Pendryrfp Cononsof thefollowinglog m1oT'3 Co
Iheve pmvida for
erumCertificateM of the Labor
self-infortfortanker'sce of to O/J'W/rlllJfa/. r/
von,r provided for by Ss issued
have
3]00 of the Labor Cada for the performance of the
ave a ch Nia maintain
is ismed. r -
I have end will ude,fon Workers Compensation work
hi h result.by Section /t _
] of the Lkbar Cade,fordrcperformutce of Ne work for which this petits is issued. //
My Wmkc/�r�pemattt�nalnsurancecsni«antll'.1w�n�tu�ba�ggeyk�{y aL (�'�L
Caricr:�Is Y� Policy Nn t�0ffX{&'
CERTIFICATE OF EXESWDON FROM WORKERS'
COMPENSATION INSURANCE -
(nns section need trot he completed i f the permit is for ooe hundred doll ars($100)
or lms.) s ,
Toy. Rodno the performance ofNe work hich Nis permits iss,comphdl
not<mploy an on in any ennerjbi1y rotheWarken'Compen-
ution haws— Irs�. aro ''77��,,
NOIRent Y
NOTICEITOubj APPLICANT:IL after making this Certifn s of of Exemption,you shouts
become Subject y it W ch pro Compensation provisions of theLaborCode,you must
'
forthwith comply with tach provisions or permit shell W d«coed revoked.
0 p IhoCONSTRUCTION LENDING AGENCY
rw Nrn that there is a consumed..lending agency for the perfouaxce of ^
Z the work for which did
permit is issued(Sec.3097,Cls.C.)
F., Lenders Name
lenders Address
W A 1 certify that 1 have read this application and sine Net the above information
ng is correct. agr«to c comply with all city and<oumY madordinancessof and some feat r up ng e '
V ObWv,..miooccsogord hereby amhodurepnesentativn of this city to corer upon Ne
above-mentioned Pmpeny for inspection purposes. ,
kr Fy (We)agree in save,indemnify and keep harmless the City of Cupertino against
li.Mhum,judgmenta,costa and asposen whichnuy in any way a«me against said City -
�., G] in eo sexi..ve of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY Win I ALL NON-POINT
f..l z S REGUATIONS. -
Signature of Applicant/Contnetor _f Data r/
HAZARDOUS MATERIALS DISCLOSURE
Will theapphcanto,home Wilding«cupeo,stertor handle haurda.mmmind Re-roofs
sec defined by the Cupertino ci Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(. Type Type of Roof
❑Yes Viii
Will Ne applican orfumre Wilding occupant use equipment ordevices which All roofs shall be inspected prior to any roofing material being
emit haradova a'v conwnin. .define by the Bay Arca Air Quality Menagament installed. If a roof is Installed without first obtaining an inspection
°"ni`t' � I agree to remove all,new materials for inspection. Applicant
❑
,as
I hav<mad anrduus mamdah tryuimmcnts under Chapt«693 of Ne Gli- Understands and will comply with all non point source regulations.
fomu Hee S y Cade,Sectio.25505,25533 end 25530.1 undersand dot if the
buildin n nen arsons.Nat it is my m nsibiliry m notify the occupant
of n1 is tPon'toisau c Cero so,
pa�fm'allaf(/J� _
Signature of Applicant
O With .red agentDaft Date
All roof coverings to be Class`B"or better
OFFICE