02090122 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
21405 HOLLY OAK DR ABLE SEPTIC 020901122
6NWIS ATE
520 REED ST. APPLIc0909/19/2002
.� PHONE: (408) 377-9990 SANITARY NO. CONTROL NO.
COO ARCHITECTIENGINEER: ♦ BUILDING PERMIT INFO
w C BLDG ELECT PLUMB MECH
f—I I=.1 L_l
a S H= LICENSED CONTRACTOR'S DECLARATION Job Description
o z—e I hereby oRmi that I am licensed d parvoions of Chaptcr 9 mommerving INSTALL CLEAN OUT
r=F w wish Section of Division l of Ne Bu✓s�(�t and Profess.jpns odw aw my liver se
6 Y F fuall forep J effect. (/G_�77
er 0,at 6 cyl Clg LiC.x
a�3 a �dk '� d$ C� ARCHIIECf'S oQ�l�s�pcL RAT] �—
a 1 undersmnJ my plans shall be used ss public
isp0 Licensed Professional ?00Z
o� OWNER- N
p ,rs :AnycLaw fmthe OCT 0 9 —
L R DECLARATION
m I hereby uR that 1 am exem t from the C tin t
t: following fll mgremo (Section70n1Bs dProfd , n. h,or Any ore Linty $2650
O which eq n Permit t construct.alcor,ntforimprove,demolish, r repair any structure
3$ -port Henaissuance, requires theappfc n,l chpermuic signed mem
tmpa sl jwitod pSe ocirst toth pr vu si fthe f,Contractors add
fi mnsC(Chapde) ` 3650T,0 hn0p:y�ry ear qq 99 p• y INN Valuation
r 9
(c ping with Suugni7111N1) fDi nl ftheBusiness oemp o6.An v Code) q ) 'i. \_f! `lY'., - ] l.y P't�I4 :.,.
or that rein xempl,hercuoni and the avers for the alleged exemption.Any violation - I
--of notSeetion707 n by any ared do,for a permit subjects the applicant m a civil pewhy-
IofnnrmarethomRvehunartJJogars(ssl«n. 106APNN4Jl44'<i' & WATER •�:,:T`^ Occupancy Type
01,as owner of the pmpeny,or my employees with wages mteir sole compensation, 202 UNDERFLOOR PLUMBING
--will do the work,'and the urueture is no,intended'or offered for sale'(Ser'7pHl;- "-"-- _--- -
'Businesdand Professions Code:rise Commcair's License Law does not apply to an: 3 01 - ROUGH PLUY4iNQnspccIions
owner of property Who builds or improves thereon.and who does such work himself 302 - TUB & OR SHOWER
or through his own employees.provided that such improvements arc not intended or I
,bR dfrsale:H;n, m baaang p n, la"m ey ,f 502 FINAL PLUMBING--ENERGY-.
'com 1 tion,the owner Wilder will have the burden of that he did not Wild or _ } -
improve for Purpose of sale.), pro"ng 506 GAS TEST
_ _ -G71asownernnhe'property,am exclusivelycomrningWith licenmticontractors to _ _.__.__5"07-' FI-NAL—PLUMBING_.._—._._.__._u_Iu:!v-
_ eonsuuet the project(Sec.7004,Business end Prefasions Cade:)The Cammebar's no EL-r(7 PIS'n3
License Law does not apply to an owner of pmpeny who builds or improves tcamn,
ri z _and.who contracts.for.such,pmjccts with a.contractor(s).li<easei.Pursuans.w.the._.
Conwmo/x License law;-. ,
B'&PCfthi
❑I am exempt under Sec.' or s reason Job LeSCrIi:L'C:1
Date, .. . .
""WORKER'S COMPENSATION DECLARATION '
-1 hereby aRnn under pcnahy of perjury,one of the following dalaratiau:--
❑ 1 haSi'.ad will inaini6in o Ceiiificate",f C,nicm m sel6inum,for Worker's
Compensation, as provide for-by-Scmion 7700 of the Labor Code, for the
peifotmance'af towmk,(or which this permit is issued.,t�
❑1 h bd will of t 1 Worker C scope,s t n Inwran ai rzquired by Section
3700 birth,Labor Code ftsf the perfmas.ren of the work for which this Permit is
issiod'ifyWorker's Cme,neroation Insurance carrier and Policy number are:
artt �i'V.Tj ) 1PsSPIICyty-�yt rP ab --L.IL.+1 tdh.•...�...�......�....
.rt IICERnr,ICA I ION OF,E%EMPTIQN PROM WORKERS','
... Av
COMPENSATION INSURANCE
uy (Th s senuin need nm he mmpleied f the permit is for one hundred dollars '+'k 11)r"
'IS 1o1A,r less.l
I
coolly fohal+fon tort,pe f , f 7 f the k f -, h ch tl p r's' tl I, ,a.'f „I r.
'M1'h ll ,employ any 1 en ry nun en to hetiin hie t to the Workers. 1
C PP n t Lnws CO I Dule
r'NOTICE TOAPPLICANT;It Iljnuking this Certificate of Exemption youshould, i`_I It
b oo it b i
G:Oy fNorth hh c)o ly with such provisionsC p tthis p r
Permitshall fb th deemed L M Cod ked
; '
m t '
_.
tt CONSTRUCTION LENDINGAGENCV + ._.. . _. _ _. _-___ __.. ...
... ..._ .. ... ._ ' '..
11-1 1
' +11 reby ulTmt,h t there r Dost m o lend ngg pg ncY f th;peru
(rmnu "a r
L'a muse
Rh ,d fo "h ch this pens t is d($1 3 W7 Ci C) ...e w_ ..
nders N m ., .- ... .._ __._ __------
z
.___z Lend r Address' L i)LLCI Ij`c:
1 certify that I have read this application and stare that the above information is
ki-E,t ,coma.I agree m comply,wnh all city and county ordinances and state laws relating
S Q(V LLu building constriction;and hereby authorize apesentaives of,hii city,,enter upon
7th r� ;the.1som-merfirsned propenyl a spie n pugwsa,tz _ _ -
0.- We) gree to a tademnlfy and keep ham,le.isthe C,yof Cupcnin"oagamst
%
liabilities,7udg cars,cAsu Date
sts rid tea h ch an y in any ay Accrue againn said T
U z Coy ih conaq of a 'df t, rmu �I v
" SOUkTCANTA c!ER)Ir _YD\ LCO Y'' ALL\'OS-P IYfv Issued i
$ rt r ppl antrc namnor + h Re-roofs
l HAZARDOUS MA'IERIAIS OfSC SURE 9��/fgy7p
' W II the appl ca t or f core bJ Idmg tic pant sorc,r hamlle harard- u anal t ..Type Of ROOF I
�s d f d by the Cupar n MunstWl_ Chapt r 9 13 nd the Health aM Safety
Code sea„n zss3 ( I t t '+ e CDN ik y l e 'I '•t —
ove + a r I ._All roofs shall be inspectedprior.to any roofing.matenal.bemg installed.,___.,__
I
,,; ,wu m pPl oto furore b int p tau eq fop t d ve n n If a roof Is installed without first obtaining anins ectiod I a ede to remove
'and
h rd s r c,t in nuns es d 0 by m 8 y'Are Art Qualuy Management P g
D fort I_. ._t ,all-new materials for inspection.-ulat ' Appllcant understands and willCOITIONwith
� .:r ❑Yes '. _..,.. .,. _. _
f r,. all tion-point source regulations , t ) .,r,
1 have ieod�the h4iwdn s matenals reybvcmenis� der Chepar.ti.95 of the,
,Cmtfom aHealt'B:Sufery Code,Sections 23505;2557)and 25530.1 undemand that'!
'.dfah0 building dtxs nn' remly veal am;that it ii- y spo sa'liry to riourY tai _. _. .. __ _.. .. . . . ... ..... .. ..__.... ...`.+ `..' ,....._._ _.
tic am fih ',� g ht `� „-,.Signature of,ApplicAllroof coverings to be Class B ortbetter
J, p l e ems h, t nuance ofaC d' o f
0 upo c
g
o amhor¢eJ+ent Dm
1
--OFFICE. _-._ ___....,_... __.. _._. _.. . ._-._ .. . .. .. ..... .