00080072CITY OF CUPERTINO ,
BUILDINGDIVISION PERMIT
—MUNI,: KORN, HOMER
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LICENSED CON' TIACIOR'S DECLARATION
1 hereby affirm and I am hectored uMm provisions of Clupear 9 (cammercing
with Section 7011(bofDoision Sof Ne Brou pPos' ins Cyde. and my littnee is
in full forceaM cR G yb S I
license�i a�e�� Cmc
Deu--sartF Contractor
I u ARCHDECTS DECLARATION
I undenrsM my plans shall h uted as public records
uccnsal Dofeuioml
OWNER -BUR -DER DECL0,RAT10N
1 hunch, afOrm that I w exempt from Ne Contractor, Lion. Law for the
following reason. (Section 7031.5. Businoss and Prefmfans Code: Any city or only
which requires a permit to consumer, alter, improve, demolish, m repair any smcmu
prim to in issuance. also meal the applicant for such pcmtit to file a dgoed statement
that he is licensed pursuant to me provisions ofd. Connectors License law (Chapter 9
(commencing with Section 7000) of Oivision3 of the Business end Profes.iom Cade) or
Rest he is asenryt therefrom aM de basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects she applicant to a civil penalty of
not mom then five hundred dollars ($500).
I, as owner of Ne property, or my employees with wages an Heir sole compentadon.
w it l do the work, and the structure is not intended m offered for ale (Sm. 7044. Business
and Profesdons Code: The Contractor; License Use does Trot apply to an owner of
pmpeny who Wilds or important thereon, surd who does such work himself or through
his own empl.y.a. provided that such imp rwro enp are nm intended or offered for
sale. If, however. Ne Wilding or Improvement is said within one year of completion, de
owturWilder will have the harden of proving that he did not Wild or improve for par.
pose of cele.).
E]1, u owner of the property, am exclusively contracting with licansed eontraemn to
unmet the project (Sec. 7144. Bulinus and Profm.iom Code:) The Connector's V -
came Lew does nut apply to an owner of property who build. or improv. moron, and
wh.... mots far such projects with a convumo.) licensed pursuant w the Contractor,
Licar. few.
❑ Iem bnbandec So,. .BRPCfmtbi,ncmmn
Owner Das
WORKER'S COMPENSATION DECI. MnON
1 hereby afro under penalty of perjury ane of Ne following deeclaretiam:
1 have and will maintain a Ctmfiute atonement to self -insure for WmkersCompen-
suaker, m provided for by Section 3700 of the IaWr Cade, fm the performance of the
work for which this permit is issued.
0 1 have end will onsimain Worker, Compensation Ins.... as requincd by Section
3700ofmh laWr Cade."a the ped arca of me wort for bleb Nia permit is lamed.
My Warks q Imurarm artier and Polity 0
Carrle lz4n _pabcyNo: j° $0� 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This acctio t need trot becampice d ifthe permit is foron, huedreddollen (1100)
or bet..)
I certify that in the performance of l e work for which this permit is issued, ) shill
rot employ any person N any manner so as to become subject to th Workers' Compe.-
.6. lawn of California. Dan
Applicant
NOTICE 7O APPLICANT: If, after reeking this Certiflmu of Exemption, you should
bacomne subject to the Worker. Compensation provisions of the labor Code, yen most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSOk"C'NON LENDING AGENCY
0 Q I hereby affirm that dune is. co onectima lendingagury farthe pouf ceof
Zthe ..,it fm which this permit is issued (Ser. 3097, Civ. C.)
F.. Lender. Name
' Zanders Address
[� I certify d a 1 have reed this application and amt. 0th the above information I.
CL A sorted, l ague m comply with all city ask county ordinances and stem laws mhdng to
r7 z building combustion, end hereby eutWnu reFresemarives of this city to enter upon the
eWve-mentioned proleny for inspection purymn.
Lz Ey (We) area to save, indemnify and keep hatless me City of Cupertino against
C.7 liaWcom,q
ene expenses when they in any way acme egunn said City
sus fro intin8 of ria rmitAANUti WIILC,,mPI.YWITH ALLNON- INT
s
�) OU
Sig um ofApplicantlCon actor Dae
HA7ARDOUS IALS DISCLOSURE
Wiliths.'licant or furore Wildin rccupen.nomorhandlehaysdommatedd
m defined by the Cupertino Municipal C e, Chapter 9.12, said the Health and Safety
Code, Sections 255320m17
❑Yes r1 No
Will the applicant or future Wilding occupant use equipment or devices which
emit hanrdous aR canmemimnrs an defined by the Be, Arta AG Quality Management
inner?
GYa, ❑No
.� I Air"
dud dins thaw; wncmcots uMer C'hapur 1.95 of the Cali.
fimde Meal etY • Secs; 53. 23f 75534. I uif tle
Wild; n yha LtAv iti pwibilirymndl the spent
of u ch rousted @aY 0f.Cmificee, �rmgy.
CONTRACTOR INFORMATION:
I.troor,
"/`�
i�E�R S'JSTEMS IL_
3Q �pfwr
S Z''�Lo F(*P,NER LN
5 SI 3 .x,
(408)266-8222
SANITARYNO.
BING 0087
1rte.
PPLICATIONS2UBMoTALDATE
NIC
❑
CONTROL#
08/11/2000
BULGING PERMIT INFO
302
Job Description
REPIPE
Sq. Ft. Floor Area
3691
106
— SEWER
& WATER
202
— UNDERFLOOR PLUMBING
301
— ROUGH
PLUMBING
302
— TUB &
OR SHOWER
502
— FINAL
PLUMBING ENERGY
506
— GAS TEST
507
— FINAL
PLUMBING
Re -roofs
Type of Roof
$1
All roofs shall be inspected prior to any roofing material being
installed. If a roof is Installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant
OFFICE
All roof
Date
to be Class "B" or better