01040070 TINO
CJ BUOI 1 G 1MVISI
ILONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: , APPLICATION SOB DATE
/16/.
PHONE. SANITARY NO. CONTROL NO.
O C PHONE
BUILDING FERMI 'O
BLDG ELECT MECH
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M m LICENSED CONTRACTOR'S DECLARATION
0 Z y�` 1 thereby afemi that I am licensed under provisions of Chapter 9 Job Description
o z— p leommeneins
PHt_� whh Swtiorce and or❑ivlwinn9 nf,ee Husinexx and Protusslure CnJn,mA mylleense
a& �, is in full force and of�f�,I�
`nu c'uc`_L+j(p_ Linnston _J`� REPLACE SEWER LINE FROM C/O TO SIDE W
w ate commune
ARCIi O'ECp'$DECLARATION q /
tj g I undmnand ni,plans shell he used it,puhise renmdean wi �pj/7Ja
Cso Licensed Prouticn,b ssional /
c fS o OWNER-BUILDER DECLARATION
ttli I real.ufMu thal 11. exempt Tann the Cnntru,Co Ali,e law II"my
f(=Z a following aawm.(Section 7x11 5•Business and orafessione C,or Any an do chars
3 m which requires n permit re rnresthel,alley,improve,demolish,or repair any sleuaure
pial
rtn is sensed is also requires thcv,,i.c d for wchpemm�ofile ensei aneJ Chillier
nI'llatxhanscdNeaimtmmepr..vb,aosn3of'tire heInains,naenprLawonsCoo Sq. Ft. Floor Area Valuation
(commencing with Sell an oun gnat e loris 1 lir me Buninees and ion,Annie Gxlcl
I),ma he is cnanpt Iany aiom and Inc basin fns Ibe allege)e.empnob,Any k pennon
of Sedinn701ir it anyapplicantantroe apermit euM1jecb the applicant Inacivil penalty
ornmmarcmfnEvth.mdreaaouart(ss(nL APNNumbeT Occupancy ype
D 1.asowner of mm
e praised,or y u,nployee wgcsae hh watheir sole compensation, -
will do the work,and the swcmre is not intended or.1hr ed for sale(Sec.70W, 36922020. 00
Busme s fail Professions Code:The Contractor's License Law does not apply nt an Required Inspections
owner of property Who builds or improves thereon,and who does such work himmlf
lir through his own aoployces,p,ov,Jcd tha each impnrvancnts are not intended nr
altered for suit.If,hnwece,the railcar,or intpmvemcnt is sold within one year of 106 — SEWER & WATER
omplifion,the owns,-huilde,will rase the burden of proving thea he did not build or
mpne.forpurposcnfsale.), 202 — UNDERFLOOR PLUMBING
D 1.as assic,..1 be Pmpen,an,c.cluxlvdy eamor,ar,war licensed eonne,has to 301. — ROUGH. PLUMBING
1wmun the project(Sec.7634,Ilusinesx and professions Code)The Can I....... 302 — TUB & OR SHOWER
License Law dues nor apply to an"carer of popery%he builds or improves theresnt, '
and who contracts tot such projects with a coulracmdsl licensed pi,ited to the 502 — FINAL PLUMBING ENERGY
Conraaor's License l.nw,
0 l an ewer ,under Sce. ,11&1'C li+nhi,eeasnn 506 — GAS TEST
(Inner ue
WORKER'S COMPENSATIONDECLARATION 507 FINAL PLUMBING -
1 hcrchy affirm antler pefully of pe jury one of the Iisllowln,declarations:
0 1 have and will maintain a Ctaifcme of Consent to self-insure fur Worker's
Cornpanxn.ion, as p,'nvlded air by secfinn JID6 of the honor Ede, air clic
perronn.a of tee work tin which fids per nit is Issued. . .
01 hair and will mains in Worker's Compensation Iraoraneel concluded by Section -
37M or the Lahnr Gide,fill Ibe pedi+rance of the work far which Ihis permit is
va,ed My V�arIs Cum ration Invur"nce turner anal Pulley n odwr are:
'—[Y Policy No.:
CERT OP I?XEMITION FROM WORKERS'
COMPENSAf1ON INSURANCE
(This section need not be cannpined it he peril is far one hundred dollar
CSI Off in IsssJ -
I tinily that in the perfom+ance of the work lin which this peinde is issued,I
shall not employ any prison in any manner sir;u uo becmne subject to the Workers '
Compensation laws of Culifomia.Date
Applicant
NOTICE 10 APPLICANT:If,after akin,this Cc tilic:ne of E.cnlpninn,you should
Z 0 become object o the wo,"e,Can,pncmio ipso, msnl lee Lahnr Cade,you mux,
forthwith comply wan such precision—,this premie shall he Deemed revoked
CONSTRUCTION LENDING AGENCY
a ;' I hcrchy of re Ih ll there is a consxaaion Iendiny h,incy for the perfarnumce
of the work for which this peri,is issued(Sec,1097,Civ.C.)
L Q l.cr let Name
Z tanner's Address
V 0 I certify Ihal I aloc 11.1111111 upphalet o;;load one it the chose inform"aon is
Fr F correct,1 agate to cmnply with all city and county oNhnerces and state laws retain,
O V ,Wilding constmefinn.fad hereby atantri,representacves afil i,cart.cle,upon
} r� the aWvt.mcnroned property for inspcnion pts"Ise.
�.1 W (Wdugreeta.l indem,tirr;md kern lavmless,hc City ill Cupeninn nguin.a
linriliti,"judymenu I,and.."res,which any in u way accrue""cion said
U z Cilyincansecaere rine,mrtin,ofmit ran.
APPLICA ER No. 4N0 COM WITFI ALL NO
g Issued by; - Date
6
Y�
bitches, -A y ram E.I Re-roofs
H RD( S AfATERIAI S DISCLOSURE.
WillNe appli. Type or(mens FvIlJing aoccuNm num ai hunm<hvuNouz mfa•Hal of of
ehned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety ,
ale,Seen 125532(07,
0Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Wi 11 the applicant(it future building occupant use cluipment or do ices which If a roof is installed without first obtaining an inspection, I agree to remove
mail hazard.....air csniamimnts as defunct by the Bay Arca Air Qunlity Muna,nnenl
,rail
all new materials for inspection. Applicant understands and will comply with
D Ye` 0N all non-point source regulations.
I have read the haamdonv nmmrials negriori under Chapter 6.95 of the _
C.Hiftaniu l laallh&Sal.- odc.Sonine,255115,25.133 cf,11.5534,II lersumd thin
if the buildia,does n . rely have a anal,Oral it ism spnnxihilily l9 ratify the '
m of t cub which must tat prior .seance of niB m of
p n'
Signature of Applicant Date
two b/ All roof coverings to be Class "B"or better
OFFICE