02050141 CITY t DNG mviSio NO CONTRACTOR INFORMATION:
PERMIT
Bup.WDl(',�DDRFSSILLICK WY PERR1MIITgNO.
µ 02050141
OLI/3N�L�lGA A1/7/ LJS�G VTl�2
PRONE: SANITARY NO. CONTROL NO.
O O ZZ ARCHITP.CrENGINEER: BUILDING PERMIT INFO
❑ BLDG ELECT PLUMB MECII
Z uo
O�Z ATION
I hereby affilrmF'tM1hat I am liceSED nsed CONTRACTOR'S
provisionsR Cheaper 9(commencing GAS LINE TO ICI��Ipgcrlptlon
i_Cumi with Section 7000)of Division 3 of the Business and Professiom Ced,wd my license
o z-+ in full force and effect.
uLicenseClass Lic.a
a. Dole Contractor
a O aARCHITECT'S DECLARATION
Y
1 understand my plws shall be used as Public records
y -
I a p O Licensed Professional
OWNER-BWLDCR DECLARATION
-m 1 hereby air,.that I um exempt from the Cnthwm's License law for the $1000 IZ? follow ing reason.(Section 1031.5.Business and Professions Cade:Any city meal $10 0 0
D wh h reaPines.pool t n,true all,, improve,demolish nr cepa r my svucmre
co
pri t ncc,ul rey the pplicum for such perm uo filevs BncJ uaiemem --.... .. ._.
- that bell,llctnsed puisoanna the provisions of the Contractor's License Law(Chapter 9 _
(comma cng with Section I?")of Division 3 of the Business and Professions Code) r ' ` • t' )q Sr% � Valuation
or Nat he is esom i theicfmm and the basis far the alleged cleN won.An
p B P Any
of Secnot ion more
thin iv tiny hundred
cam ollars $500).it subjects the applicannoacivil Penally ,ryp
lot not than five hundred dollars(`500), pN :r OccupancyB
CL as owner of the property, employees with wit wages their sole compensation, 301 - ROUGH PLUMBING
p per r6= Pte 7
will ne the work,undine ode:Tstructure is not Contractor
ded a Lie offered for snot apply to an
Business and property
W tom Code:The Contractor's License Lew Jas not apply tow r sp
owner of progeny woo Mums or Improves therms,and who deals such work himself 5 0 6 - GAS TE S
or throw h h s own empl y provided that such improvements a. t intended or
-.offered f r sale 1r however,- the n ildin 'era r :or -'- - -'• 5 0 7 -- -FINAL--PLUMBING. .._.......
ger burden
provi.s that
"
improve an,the use of solder wJl have the burden al pronng that he did not build or
improve for Purpose of m1eJ.
I as owner ol'the --- "Film
pSo..7 am exclusively d Profess with licensed conal m
_ construct the project(Sec. to a Business win Professions Cade)The Contractor's Is�G II�
License co dos not apply to m owner of propcny who builds or seimproves thereon.
'.- and raco.contnens L weh pe3mis with o.conwnoKs)licensed pursuant to Ne --.- ---- JUN 1 2002-
0 Comas License Law, 9-1
I pry her Sec �' B&PC for this mason .,
` WORKs<ER-S NA /AJ.
BUILDING
I hereby affirm under penalty of Pell use of the following declarations:
d1 ❑ 1 have and 'will'anduldr a Cenificme of Consent to self-insure for Worker's
0�. Campensmion, vs provided In, by Section 37W-of the Labor Code, for the
Performance of the work for which this permit is issued.
!_ C I have and will mdiisdh Worker's Compensation Insurance,vi required by Section
37W of the Labor Code,for the performance of the work for which this permit is
t7 issued.My Worker's Compensation Insomnn carrier and Policy number arc:
..... .... .... ,. '- - ' -_ .
Carrier y j. 1 ._.. .• _ - _ _.-_
rPolirN ;, {.t. k, i v t Ir' f r :-). \ 1 .-t
CI RTIPIC:COM 0I6TION INSURANCE
FROMWORKERSg - s 1.. ,h ,.°6'�.t. .,
COMPENSATION INSURANCE" '
i
Mris.,rhdr iieed not be'completed if the permit is for one hundred dollars " - +�°'(•')"''`
x(51 W 7 or Icxs.)
I
.�s. I certify thin in the pert f th e k f tech tin Perot i'smad,l - �. •�
shall n t employ nyp s o}yIs, _M1 t t yh Workcm ''' `1 lit
L'Ompce�O n�a Lew Iart
5/¢
NOTI�f�.the Wckt?s a ft mokingthrsCm team of Exemption you should .. i
z becomesubjectcomply
the Wok p C !.ns or
h is pronsmmofthe edLabor Code,you..it
Q Q
forthwith c nply with - -h pm 'I ns or thu permit shell be Jmned revnkcJ
z w o,.-, a. ...1 ....... . . .. ..- __. -.. .- __ ._ .- _.. . 1.
CONSTRUCTION LENDING AGENCY - +•" 1 t l
ai I h br ahirm that Neie o co t n c lending og n y f theprfortnwce r ,
of wforork which th p' a eJ IS 3P9'I Cis;C)
y-Q - Laul Nume _... _- .. .. . .. _..
.7. Lender'i Address.•
V'0 "Icenify that l have mad this application and state that the above imormction is
PW 'clih'en. 1 agree 3o comply.with all city and county,ordinances and state laws relating
0 V to bu tiding construction;and hereby authorize repmuntatives of this city to enter upon
w the abo(We) ndonedagree 1.proprry for inspection p hxrmlxa,
L
(We)agree is scosts and
expenses
and keep hi h may in
City of Cupertino st aid
Z city in co sequence costs and expanses winch may in any way acore1.a against sold
fJ r� City I conugUND of the NDS AND
D Nis pemut. N
SOURCANT UNDERSTANDS AND WILCCOMPLY NTPH ALL NON.POINT- Issued by: Date
SOURCE R ATIONS' I '.'�"� . .
Signal ofAPPliwnt/Com er' -r " rGlue Re-roofs
r - - . HAZARDOUS MATERIALS DISCLOSURE
Wit ;
' um ppl um or tutu ebulld'got upam amu or handle haxallo atonal . Type of Roof
gas defined by the Culacil Municipal Cmd Chapter 9.12.and the Health d Safety -
Code Sen o 25532(x1 r . r, -.e F 1 ) t + , )' t -.._ ... .. •, _
❑Vs i.%- c: D No. i t { 7 . 'it . . .- r
T, .-All roofs `hall-be inspected prior to any roofing materia] being installed.
emit hamoomse aeatamments as define` "p t A is Ai toe a wit to If a roof is installed without first obtaining an ms ecuori, I a fee.to•remove
Will be app'cam eft rcm,ldi
ed by the Bay Aria Air Quality Matiagemem P g
oatrct all new materials for inspection Applicant understands and will comply with
+ n. t all non-point source regulations: .,;, ,I
I have read thebaaardmea,mievol mgmremeini under Chapter6,95of Ute
Californid Health&Safety Code.Sections 25505,25533 end 25534.1 understand that
-ifthptan,oing doeshot uncits which
manam,Narior myresarceofa idnficat the
or
c pant of ltiarequir m nts Itch must Worth prior to issuance of a Certificate of
is Occupe y
. Signature of Applicant _ Date _
-r: All roof coverings to be Class "B" or better
Ow n diothed sge Doe . f,'
OFFICE -. .. .. ..._.. ..- . . _. ___ ._- ..._.. .