00070106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS. 1117RMIT NO.
OWNER'SNJ72 HOLLANDERRY PL BUDGET PLUMBING APPLICATIOby$t;1i D4T-g'06
HONE: SANITARY Nt�ILIf��1O C(N O
Vr EDWARDS CATHEY L 28695 ROANOKE ST 67/18/�CI�`D`�6i
GOO ARCHI'IECDENGINEER: - BUILDING PERMIT INFO
(510)303-7847 BLDG Ra.rcPLUMB MItcH
LICENSED CONTRACTOR'S DECLARATION
o 5�= Job Description
°Z: I herthy a0ion that 1 am ofie,licensed under provision.mfChi 9(commencing
pv_,rJ wim falion7mlp affect.
2W
inn3ofmnBminessand Profesionx Csxle,and mylicensu ,.
R y ,a Is ce full force and effect.
E m�e a Licenze Class Lie.Is
X°a O Dale Co..hi'mr •'
.Be w y ARCHITECT'S IIECLARATION
k °g l understand,nr plan„tau rte tied a.,Pablo records WATER HEATER
ya o O Licensed l'rofcaiood
R 15 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following ration(Section 7031.5,Business and Pmfen'in I,Code:Any city or,maty
S❑ which rnrylav o pa t In colon t,alter,anprovo,denmlish,or of mr any voolare
ue,t3m
prior o its issuance,also reyuires the applicant for.such permitsd file a signed summers
Beat he ishcensrdpm.nanito the provisions nrthe nrmuchrsLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section LMP)of Division 3 of the Business and Pmfessimns Cash)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a scour subjects the applicant to a civil penally
of to more mon eve loathed dmuars Issm). APN Number - Occupan$y_Type
01,as owner ofthe prupeny,or my employees with wages as their sole compensation, 65,0
will do the work,and the structure is not intended or offered for sale(Sec 711Y1, g -
Basinesser of andpPmressioa Code:Tne Contractor Loden.Law does not apply to an 36229009. 0�quired Inspections
owndy Who builds erth
r int roves ereon,and who J,ms such work himself
nr through his own emplayecs,provided that ouch impnwcmmm,are not intended or
offered for sole.If,however,the h tildiag m int 'i"c' m Is sold ,id, ono oaf
ompletion,the owner-builder will have me buNen of proving that M did not hell)or
improve for ptrposeofsmcd. 502 — FINAL PLUMBING ENERGY
01,vowo.,of the proveri am exclusively contracting with licensed comractnrsm 506 — GAS TEST
Lonstmet the project(Sec.7814,Business and profusions Code:)The Contractor's
icense Lew does a,apply to an owmerorpmparty,wm bulli impmve,mercmn, 507 — FINAL PLUMBING
and wan contracts for such pmjeas with it eonmmmns) licensed par oath til the _
Contractor,License LAW. f�
❑lant exempt under Sec. ,Il&PCfor this mason
Owner Dam
WORKER COMPENSA'I'I(lN DECLARATION ^�
ffir
I lai
and will
malt, a ler ofche of Ino sent to following dcel•nr Worker's
ort
J I have and will provided
maintain a Cenificvm of concent t mLatiorc for xorA the
Compensmien, he providcJ for by Section 37m of the labor CWe, for the
perfom,ancc of the work for which this remelt is issued.
❑I have and will main
min Worker's CoanNnsntion Insutnnaq ns rnpaireJ by Seudon
37011 of the Labor Cale,for he perb,mmnce of the work sur which this pennil is
ssueJ.My Worker's Conywnsution Insurance curtier and policy number Ura.
Caricr. Policy No.:
CERTIFICATION OF ENESII'NON FROM WORKERS'
COMVENSXUON INSURANCE
fDid,section ncN nm be camplecd it Ile permit Is I..nmc hundred dullurs
(SI W)or las.)
1 cenify that in the performmKe of the work for which this permit is issued.I
shall no employ any person in any manner so as to became subject to the Worker%
Compensation taus of California.Date
Applicant
NOTICE TO APPLICANT:It.after making this Cenifiemo of paenrtim.yea should
Moor subject subject m the Worker's Compensation provisions of the labor Code,you most
OZ
O Ross,ith comply with such provision,or his permit shall he thereof revoked.
f+ y
CONSTRUCTION LEN0ING AGENCY
1 herthy which this Thera is a nmstu.See097leading Co.C) for she p:rfannancc
Til of the work for which mis Nonoil is irwed(.See 3097; v.C.7
Q Leader' NSmc
� Z Lender's,Address
I cenify that I have mad his applicmion end tam mtn she above information is
E.. coven.1 agree to comply with all city and county ordinances and state law,relining
O [) •mhudtling cotshuctme.and hereby aumori,n repmsenadvex of this city to enter tram
W she ahavnmentinned pity t'ar impood....I.. sats. '
Q. (WOoloseto save,indcmnily and keep lernJessahe City of Cupenmo against
Z) liabilities,judgments,costs and expenses which may in any way accrue againn said
(.) Z City in cnnuqucnee ofthe granting of mis pennil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Is$Iedb
SOURCE REGULATIONS. y 7 Date
Signatemil A,IlcnnUCr ocp1or Data Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE
WilltM applicant or fpmte building acmpam nmeor fin lie Imitations numud 'Type of Roof
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cede.Section 2553201'1
0fei . °No- All roofs shall be inspected prior to any roofing material being installed.
Wit(tic appl cant oa 0tnre bui ding occupant use agtdpema or devices which if a roof is installed without first obtaining an inspection, I agree to remove
molt h.ousa s it id nam,rents a,defined by she Be,Area Air Quality Management
,i.tdct^ all new materials for inspection. Applicant understands and will comply with
Ores 0 N all non-point Source regulations.
1 have rend the hamrdou,mmerims reyvircmems under Charter 6.95 of the
California Health&Safety Cnde,Sections 2550 25533 mol25534.1 ondershmJ act
U
she ani lding does not currently have a mnam,thio It is my responsibility m notify the
«cupant of the requiremenrs which mull h awn prior m issuanec of a Cenificoae of
Occupancy. Signature of Applicant Date
Owner or omnorized agen - Data All roof coverings to be Class "B”or better