01070045 OF
CI BUILD NG DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22091 HIBISCUS CT CUPERTINO PLUMBING 0109970�s0yy45
'Y8909ON ROBERT W AND MARY L 10297 S DE ANZA BLV A07/T12/2001
PHONE:� SANITARY NO. CONTROL NO.(408) 283-0618
�Z ARCIII'IECf/ENGINEER: BUILDING PERMIT I FO
to° BLDG ELECT LUN MECH
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LICENSED CONTRACTOR'S DECLARATION
Z"sy 1tion7 for-Doer 1nm of the B under n of Chapter. (commencingJob Description
���° with Section]OOOIo(Division JofNeBusincssenJ�Pmf<ssionzCale,and m EcensREPIPE & WATER SERVICE.
<''— is in full force and a t. y
,z� Dam'eca'x D<.n L� (COPPER REPIPE)
n'0 a, Data Contac
w 3 u. ARCHITECT'S be se DECublicKKAT ON
I understand my plans shall W used as public records /
ams p Licensed Professional
d OWNER BUILDER DECLARATION
utM, I hereby affirm that 1 am exempt foam the Contractor's License Law for the
following reason,(Section]0315,Business and Professions Code:Any city orcounty
t�C which requires remit t t t Ite improve demolish.o rep Ystructure
a3_ Pr t m enl 9 NPVlrntl _..._.-" _
barn arc 1adp,s cat U,the Provisionsof the Contractor's License L (Copt 9 S Ft F100M1ACea , �. 1 Valuation
(co nbgwth Seuon]WO)of Division JthBsi s and Prfesswro Code) h.,'I,d.'> 91l.1 i1 ,,I, .;Ei , i.,. ji.n_ss: t
or that he Is exempt therefrom and the basis for the alleged ciampdon.Any violation
of Section 70315 by any applicant for a permit objects the applicant to a civil Penalty
;iron,...short five hundred dollars(5500). APNNumber4- : .. Occupancy Type
01,as owner of the pmpeny,or my employees with wages as their sale compensation, 202 UNDERFLOOR PL BI^�:1NG
,W Jo thewarK,-and the smuctumIs not intendedor ofrcrtd-for sale(Set.7041, 301 — ROUGH P1�Ia'�fAlCaspections
1Busineas ,hitProfenioThten
ms Code: e Cas or's License Law does not apply men
awn,,of properly Who Wilds orimprovaflarmon.aadwnodoes inch work himmlf 502 - FINAL PLUMBING ENERGY
or thmugh his own employers.provided that.such improvements am not intended or _
_ .... ...._._.. ..._ .._...__. _ _
soercdmsale: whowever,the Wilding of improvements sold within one year of — FINAL PLUMBING t .t
improve for the pom of tIc,).will have the burden of proving that W did not Wild or
improve for purpose of sale.). {
❑I,a t mer of Ne propenY,am exdus velY camocung with I censal contmcmrs to i .__.. .. . .. _..
License
the projecteno(Sec. to a Business and Professions Code:)The Contractor's 4 t : YI
License Lnw does not apply to an owner of property who halide or improves thereon,
n
..and who contracts G ow. , .protects with a contractor(a) puccuanrm Ne . ... .. . ..
CommctorsL(an
La .
_ ❑tete esempt under Sc � � -'�- � t � t 'R&PCfor this,reason '1,h y i., b.• ,.
Owner' ``' "Date'
WORKER'S COMPENSATION DECLARATION
1 hereby aRnn under penalty of perjury one of the following dalmatians:
❑ I have had s ill'maint$in'z'&rtificme of Consent to mlf-insure for Worker's
_ Compensation, as-pmvided for by Section 37W of the Labor Coca, for the
perfmmence of Ne work for whichNis permit is issued. .,
LbNh tte unJ will mbintor Workei's Cmartusation Inamorata,os mquircd by Seciiun
3700 of the Ldh6,Code,far the performance of the work rot which this pemot is
1 �pae r c end Policy he .
ICfRTIfICAT10N F,EXIcy NoT_ a sl4. F! Ar I f f
t e'
C �PFON INS FtNCI!7 ERS s, - f
COMPENSATION INSURANCI.
(The metomae4rim W completedf the perms ,far one hundred dollars s 1
(SUC),w e's.) .
1templ yam m the n in any c im the rk fur which this pc t tin'e -
shallCom n employ any parser n anytwo r m as tohome b)ct m the Workers' '
Compensation laws of California.Dae
.'Applicant
NOTICE TO APPLICANT:the WT a Cma,ark',gth Certificate theof empi ,yaouslamild
most "t
hecmani hwithc lentect it W k I C mpeni t provisionst] a IvWr Code.You must
0 O forh nE c -ply with such pro 's ons or th permit shell be domed voted.
i—_.. ... .. _..... .. _ ."._
CONSTRUCTION LENDING AGENCY t ''• -I•'•''I` 1
I heicby ufOran that there is a constmaion lending agency for the perfo n ance -
YiQ Letit Name 'work h chN Permit ss d(S 7(19] Civ.C) �' .. _ .. .. ..... . .. .... .....
Lntl sAldr,
t-� I art fy that I have read tti s applic t on and sure that the above mromtation is
les.F cormecl agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize mpraenotives of this city menterupon
the abgvumemioncd properly for inspection purposes. ___
Pr
(We)agree to sac;irrationally and keep harmless the City'of Cuperuno against
F'!q liabilities,judgmcme,costs and expenses which mvy In any way accrue against said
U Z City in smosquirracis ofthe granting f this Permit _ yyY>
A taNDEI�CTA. SANOW'ILLCOMPLYWrfHALLNONPOINT' /�J
s cE@FQI LAryhs `f Z� ( Issued by: Date c� /
st t�Ap aero t to , .:mate. Re-roofs
f HAZARDOUSMATERIALS DISCLOSURE - 'o
Ne pplica t o future W(ding a uPant norc unhand) hwaN tet 'al, ._Type Of RDOf,
as d rncd by the Cupmiobn Mcipal Code Ch q r 9.12,and the Health and Safety „ v,,,
Ciide Scion 255J2(al t + Y; t �. •.) k a' �. . ) As.' t.is 5 l o; „ 1, •.. .- ...
❑vee ' ❑Nn a; '/' i q.l ', ; __-All roofs shall be.inspected priocto any.roofing material being.installed........._....,_ .
Will thea applicant`or f t m building me you nee equipiniont or devmss which i If it roof is instalied'without first obtaining an inspection;'I''agre9 tonremove
conin hrr,nmoo,air contaminant'as defined by the Bay Area Air Quality Matiase-cant
INstnsn : " '• all new,materials.for inspection._Applicant understands and will co.mply with-- .,
,; - ' .. all non-point source regulations.,
I have'mad the haianlous mans M505.25533 and
a d 255 Chapter 6.95 Bf hat
Celie buil Health s Safety Code.Seniors 25500.t it
and 25534.I understand roar'
if the building docs not currently herein tenant,that it is my responsibility io notify the "
a n'of th equire cots which moa be met prior m issuance of a C<nificare of
ecu aney
,.� _ L .•�_+Z��_ _ -_ Signature of.Applican[,.- ..- - -_ __. _ Date
owner uaborzedagent.: Date., All roof coverings to be Class "B" or better,
OFFICE