00060123 clTm DIN uPESION CONTRACTOR INFORMATION:
PERMIT
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BUILDING ADDRESS: PF.RMI I'No.
9
OWNER'S NAMII: APPLICKI'(ON SUB )ATE.
0171
ONIi: , _— — SANITARY NO. CONTROL NO.
(415) SES-4959
O a Z ARCH[I ECI IENGINEFR: BUILDING PERMIT INFO
c 0 C BLDG ELECT PLUMB MECH
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Z h= LICENSED CONTRACT'OR'S DECLARATION Job Description
O fS -a 1....a nlfinn that I n licensed under previsions of Chafer 9 feanunenu s,
CzEa whh tirniam]Olap of Divi Bnl'nhc BusincssunA Professions CnJc,vnA my license
¢m pfS Is in full forte and eSttt. -
xom� uan el vs Lie.« $ZS7]]�( SHOWER REPAIR
3 LL F. Dale_3IQ 2. Commelm f>`fl�lrn ;..,8_(,�
aEl O ARCHITECT'S as i T n -z DIPS I bN
� � I underxuuul my plana rhull W used m PnMlc renals ✓C
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p O Licensed Professional
6 o, OWNER BUILDER DECLARATION O _
1 hereby affirm That I am exempt tato the Contract,,,C s License Law cou my O
ZG .1halting rerevnm.ISrinutton]orL5,Biomass iand mp1ve,daians Code Any city nfcounty .
F p which requires o permit In construe,,nheq Improve,demolish,at repair any ntruclnre
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prior its issuance,also requires the applicant let such Perini,to file a signed statement
that he is limnsWpunurna, ue pmvimme ofthe Cornracmrs Licence",,iChapmr9 Sq. Ft. Floor Area Valuation
(commencing with Section]100)of Division 3 of the Business and Pmfewiotts Cade) ,
or that he is exempt therefrom mut the basis for the alleged exemption.Any violation
of Section 90315 by any appliamt For o permit auhject the applicant to a ci v it pcnuhy -
ofnotmoretmmrvehaadreddolhars(s5"u. APN Number Occupancy ype
0 L as owner of the pmpeap,army employees with wages m their sole comprn.ratian.
will do the work,and the structure is act intended ar offered for,ale(sec.VMs, Re uired Inspections
Business and Profession,Cud *Flat Cmeracer's Liuense Law does ant apply m ua y
Orr of property Who huilds or lopmu rich work himself ,
through his own mnpbyees,provided that worm haprovamems are nor intended
106 — SEWER R WATER
Offered for sale.If,however,the building or improvement is sold within one yens of
completion,the owner-builder win have the burden of proving that he did nut Wild or .202 — UNDERFLOOR PLUMBING
improve far purprnc of sa1eJ,
❑I,r,sawmerelme, Perry,i iaxchrovelycontracting with licensed camraaaaxto 301 — ROUGH PLUMBING
construct the project(sec.7041,Business ant]Profession,Gae:)The contractor, 302 — TUB H• OR' SHOWER
License Law does not apply to an Owner of property who Wilds or improves thereon. '
and who recovers for such projects with a amfrautimaO licensed Pursuant m the 506 — GAS TEST
Contractor's License Law.
D l am axmnpt under See. '.n&P C for this..,an 507 FINRL PLUMBING '
Owner Data -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: -
n I have and will muimvin a Cmdfcme of Consent to self-insure for Worker's
nmpensution, as provided fur buy-Section 3700 of the Labor Cade, lar the
dormancy of the work for which this profit is isvN.
01 have and will maintain Worker's Comprnsuoion Insurance,as required by Section r
3]10 of the Labor Code,for the pertormm¢e of the wink for which this Pencil is
i.vsueJ. Worker's Cmnpens.ru t In.wmnca c:mier epi//l P�olicy number tor: QQ '
Ca eIQ( Policy Nm: LV��L4� fL_
CERTIFICATION OF EXENITION FROM WORKERS'
• COMPENSATION INSURANCE
(This section need no,be completed if the permit is forma hundred Jolla.
(Slgp ar less.)
I certify than in the perfommnce of the work for which this pemrit is issued.1
shall urn em y wry person in any mnnnqus�u-ygcnrpe„suhjmt m the Workers' -
Compcnsmi of C Erarr' Tn' 10 LY W
Applirano p should
N(YrICET P ELAN Lahcr m, r taco rianyou
Q Ohocomesubjevtnthe W'Orkdscmupemsminn provi,Rml , e L.aMrr Code,ysi must
forthwith comply with such provisions or this permit shall W dented revoked.
F F:m CONSTRUCI 10N LENDING AGENCY
1 hereby affirm that then is a construction lending agency for the crtnmtance
of the work for which,his permit is issued(Sec.3097,Civ,C.)
Q Lender's Name
r1. z Lender's Address
V 1 rectify ohm 1 have read this npplicvtion and.nate than the shove inrrnnmtion is
i F:. correct.1 agree to comply with all city and county ordinances and state laws relating
V to Wilding constitution,and hereby authorize representatives of this city to enter upon
the above-mentioned property lar inspection purposes.
Iy (We)a,.mxavc,mic lily and keep harmers,the Cityof Cupcni no against - - -
tale, Ilohilhies,jadgmcnrx,costs end exposes which rnny in any soy vicerm ngninst soil An�
City in consequence el the g g ofthis permit.AA�APPLICANT UNDERSTAt - yyyyDWILL MP.YWITHALLNON- I ssueIdbDate zo
SOURCEREGULATION. (J/«,p G oo Y•
siyn:nape arnnphnnnlca vacmrDray Re-roofs
HAZARDOUS MATERIALS DISCLOSUI
Will the applicant or future Wilding Oecupam.atom Or handle hazvdwas material Type of Roof -
as defied by the Cupertino Municipal Cale.Chapmr9.12,and the Health and Safety - -
Cole,Section 25532(x)? .�,/�
El Yea Ka All roofs shall be inspected prior to any roofing material being installed.
Will lheapplicsnt or fawn•building occupant use equipment mdavices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hvuNous air contaminants as defined by the Bay Area Air Quality Management
District all new materials for inspection. Applicant understands and will comply with
G Ye, �e all non-point source regulations. ,
1 have read the hamrdous materials requirements under Chapter 695 of the
California Health&Safety Craft,Sections 25505,25533 and 25534.1 understand that
if rhe tiding does not currently have a tenant.that if is my responsibility m notify the
rev finer authe requirements whic\mrV be met prior to issuance of a of Ora of
fk q e.
CfarE
b �9 Signature of Applicant Date
mon d agage t Data All roof coverings to be Class "B" or better