00110066CITY OF COPERTINO '
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nuaolNa DIVISION . PERMIT
CONTRACTOR INFORMATION:
RUIIJBNCTrlV'_S8, 9 HENF_Y CREEK PL
CRRNIE DONALD R AND
l"IrITI•RUSTF_001I0066
OWNER•S"'RNIE DONALD P. .AND M K T3USTEAPPLICATIONUBi�F/2000
•HONE:
SANITARY NO. CONTROL NO.
.ARCIIIT'ECfIIiNGINGER:,
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BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONT'RACTOR'S DECLARATION
1 hereby
'IOb DBSCrlptl0u '
uftinn mat I um licensed under pmvidans of Chapter 9 (commencing
ieffect. istthSection 70 1Divi,ion3oftheBminessandProfessionsCale.andmyliswre
is in full finer ami
CHANGE WATER HEATER
Ltecne Class Lic. p
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- Dara Commcmr
a
ARCI I I ECT•S UECLARAT'ION .'
r
1 ondenund my pWns shill be..sed a, p.hlic records
Lrct Professional
- OWNER -BUILDER DECLARATION
I herehy.alErnt (hat I all e,lato Tann the C.m.,tn', Licsmsa I.aw for the
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fallowing,axon. (Semon 7031 S, Ruane,, and Profession. Ctdu Any city or county
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o which asinine, a permit to rainwater, alar. improve, demolish, as repair any armature
pn to it'ulsategofms the applicant fortiethpennir m file a si,mal,Wtemenl
that he is licensd Pursuamto the provisions of the Contractor.. License Law (chapter 9
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SqFtFloor Area
Valu Utl
(....financing whit Scel ion ](NIB) of Division 3 of the Buslncvs and Professions Ca le)
..r thin he is exempt Iherefrnm Ind the halt' for the al lased ascannion. Any violmian
i YJ
of Section 9031 S by any applicant for a permit subjects the applicant to a civil penalty
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of nm ane than fi c hundred dollars S500).
A e�N(�] n7h�
g
Occupancy Type '
❑I fthprpent Y ply tit g.'_tit I nilsramr.
34.4 tllZf 8. 00
will tit A and the structure t t led ca offard far alla har 704I,
e e n
502 — FIN f -1L gI�LUh1R'I hi €NERGY '
Bmineo,ad Is ficomr, Cd The C t an'. License Law does not apply toas.
owner
or of property, Whobuilds or improve thereon. and who does such work himself
or his awn employees. provided that such improvements arc not intended or
offered for sale. IL however, the building or improvement is sold within one year of
506 — GAS TEST
iomplatirm the owner -builds, will have the hnNen of pawing min he did not build or
mpmwelbrpaqu,vcoltule.)-
:
507 — FINAL PLUMBING .
m
, of the pmpcnY. aesdastad, subtracting with licensed summations In
miniver 'he illegal (sea 9(µL Business and Professions Code:) The Contractor's
L cn,c Law news not apply m m owner of property who builds or mr,owes thereon,
is l who contb.0 ILr such projects with a cmmmctons) licensed pur,unm to the
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C drinh is License Law.
❑Iit, ido er. B& P C far this mason
Date
WORKER'S CUM PFNSAI'[ON DECLARATION s
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hereby alum under penalty of peijury ..nc of the following desli mtions:
I have and will maintain a Certificma of Consent it, sdf-imine, far Worker',
,noncriminal, as provided for by Section 3700 at the Labor Code, for the
relational, of the wick for wnd, his permit is Is,m,d,
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❑ 1 have and will maintain Worker's Compensation Insurance, as"mind by Section
3700 of the Loki Curse, far the perfonnmee of the walk for which his permit is
sued. My Wader's Compeneuiab insurance carrier and Policy number ire:
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Carrier: Policy No
CERTIFICATION OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
(This section need not be cnmpletaA it the permit is far ane hundred dollars
($1N)... nese.)
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1 certify that in the perlinmame of the work for which this permit i, issued, l
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shall not employ any person in any manner so as to become subject to the Workers'
Compensation Law, of California. Date
AFplicum
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NOF ICE TO APPLICANT. ll; ulcnooting this Cer ifcata of Ea,um an. you should
became subject ht the Workers Compensation provisions fthe labor Cale, you most
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forthwith comply with ... h Provisions a, his permit shall be deemed revoked
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I CONS "IRUCI'ION [.ENDING AGENCY
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I hereby allinn mat them i., it comarrellnn lending agency for the pmtcomenee
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of the work far which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name -
Under's Address
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1 sena, let I have read his application and stare min tw tbase in0'urmalum is
n) m9. 1 agree m c..reply with all cry and .army amiama,e and state lows returns
building
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construction. and hereby mmarirc represemmive, ar this city to enter upon
the am, e -mentioned propenY for inspection purposes.
(N'e)agrec to save, indemnify unJ keep bonnie,, the City of Cupertino ugdnn
cons ami e'pcn,m1 waralitnay ivory way accrue against saiA
/�
oju (loacc,
City
CityincAPPOVANTU
D kthegruntingDsokpermit.
-SNDSANDWILI, COMPLY WITH ALI, NONPOINT
AR
.Issued by:
OUN OIN 11 AT
Dat
;nurc ofA,lican/Commcmr Dole
Re -roofs -
HAZARDOUS MATERIALS DISCLOSURE;
Will the applicant or Whom building accupant score or handle harnnnu.s material
Type of Roof
as defined by the Cupertino Municipal Carle. Chapter 9.12, and the Health and Safety
Cult, Section 8532(a)9
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0Yes ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant arms building occupant use cyuipmem or dr, tors which
,.it harannus defined by Bay
'If a roof is installed without first obtaining an ins ection, I a ree •t0 remove
$ P $
at, atmamiomu s, the Area Air Quality Mamgemet
tanctt?
all new materials for inspection. Applicant understands and will comply with
Yes ON. _
all non -point source regulations.
I hove rend the haeonlau meodale naluircn.da under Chaper 6.95 of the
Cohlbmla Health & Safety Ctde. Sections 25505. 8533 and 25534. 1 understand that
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if the fuilding doe, not correctly have a ens... that it ismymspombility m iraifythe
c antof the "n,cars which man he not prior to issuance of a Certificate of
Occu .y `
Signature of Applicant Date
,nneror ari,edagent Date
All roof coverings to be Class.`B" or better'
OFFICE