02030017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
PLUMBING
OWNER'S NAME: APPLICATION SUB DATE
CUPERTINO DE ORO CLUB INC 2420 PRUNE AVE 03/05/2002
PHONE: SANITARY NO. CONTROL NO.
(510) 438-9000
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
L=t CI L-1 II
e N z LICENSED CONTRACTOR'S DECLARATION Job Description
D i_� I hcrtby li irm that 1 am licensed under provisions cf Chapter 9(commencing
-vttuj is with 5eclion]0n0)o(Division Jafthe Business and PmfcssionsCode.and mylicense
(u11 ro REPLACEMENT OF SEWER LINE FROM BLDG TO CI
a,yf in Ec
x o�u L1etc°a C iiend etg sS ocir.l r 6 -7 4 CLEANOUT.
3 u.vii Bl', S DECL A' N
-L`�g 1 uneershand my plan.shall h used as puhlic records '
'y3T
y o O Licensal l'rafessional
OWNER.BUulm ft DECLARATION
=' 1 hereby by.(fithin mBerne ft..,ba a . om the Contrns Co License Law boom
?a which ing reason.(Section IDJLS,Businessand improve,
de Professions Code:Any ci,y or manly
Sd D which requires ap,alsore conaweL alter,impmve,demolish,ore a sig anystruemre
pnor l°i¢issuanca also requires the vpplicmtfor suN permiuo Elan signal sm6lrlent.
Nm n£i:uep�tea p.iq"seem iq Np poNamm anne canaaetora Luna.law(enemer9 Sq Ft. Floo[.�ew�eaz 4.(r5. 'x cion
(commencing with Sectium]0g0)of Division 3 of the Business and Nphaga sCode) •f�{INT ! rA; •i l.f L; Ai\1:C1A.N,1.t4.i fru(.:
or thai he ii exempt Neiefeom and,hc basis for the alltge5.eiemptba.Any violation
-aPSec,im 0031.5 by any applicant for it perm,subjects the applicant to a civil perally
Int norm Nen five hundred dollars a50Oh bgo it Occupancy Type
O 1,as owner of the propcny,or my employees with wages as their sole coinpenamion,
"
will do'the'Work.and the'so.clrm-is no,intended br'offered for tire'(Sec:0044,- - - ""- ----UNIDERF - - - - - -
t Businesa'.nd'Pmfessim¢Code:The Contrac°rz s Licarm Law docs not apply to an p C]ODS
owner of property Who builds or improves thereon,and who does such work himself 301 - ROUGH P
1cn3cied IF his employees.provided iijori pilich prover t hnot iFntmidedor ....502- --- F-INAL--PLUMBING--ENERGY----
o d o s l If o'bu th b IUing o rip emenis-soldat thin one year or 1i , .t
imp...a on,,he ower-budder will have the burden of proving that he did not hmW or 507 - FINAL PLUMBING
impmve for Purpose
of saleJ.
_. r g_OIa— _ with li.c_en,se_ddccontractors to
conrm thep 3 ct(Sec 70 ,Business and Proru ons
Cade)The Comrncmi s '
License Law does not apply to an owner f property h rov
builds or improves thereon, Ls''' t T
aad -with. - -
_ .who, ,m acts for such.projects u Ih c wt -a)licenced to
ced p real .the
a
Contractors License L
❑1 pt ndi, ac. - ' B&Pcflflolmsoi i ..l tit
0
wner Dote
WORKERS COMPENSATION DECLARATION -
'"' t he by firm undejput,, f pe0ury one of the toll g declarations:
rjo
�-t� ❑ I have and'wiB'maintain's ecni0cam of Conserr to self-insum for Worker'.
eom,rivoion, as provided for by Section 3700 of the Labor Code, for ,he
perfarmance of the work for which this permit is issued.,
❑1 have und'will Minima'Worker's Compensation Insmance,as required by Section
3](10 of'be'Litho,Code,for the performance of flue work'for which this pcmm,;x
issued,My Wok Compensation lass a amerand P.1ir,minernerim,
5.
IIr„re I, Micy ]
`]CERTIFICNnON OFEXI] F 91DURS
COMPENSATION]INSUTANCE'LIs",1 G2. {•alt lt.t. '' �n'S¢'�i,+M,y{,,1° 1I. R1,..L',IF it.tlJf.�T.ISL�i(.ryr rlrl. ''
L. t.. ...1
,t"'s(Tlr s secndn need not be completed d the perrn t is f r one hundred dollar , '` 1 ' ` "1 .17• ) ':
(S 100).It 11csa) t
.I I
certify any Person
the erson in rice ser the w rk far becomwhich N j.Ft m d tWorissuke,l _� H ` I t . 1 �v.1
shall not empl y Laws
of alit n any manner so as to berome'sub3ect m they Workeri ' .I t `' Is h L
Corpensotion laws of California.Uate'
cAnj'
NOTICE TO APPLICANT If 3(mr make thsCendcme of Facm tion.you should
B P
bee me abject y theW rhe s Compensation n pro it ons of the Inbar revoked you run
0 0
forthwith c n---- N such previsions aro Nl permit shall be deemed rtvokcd
rt'tq i
"' �CONSTRUCTIONIENDING AGENCY' 1!'r1 h by aYT th t N rt u a connrn on le ding vg n y fo the perf c rw k[rhkh N, part , d(S 309]Cv C)sNanie ..� ., ,. ,. .,.:.._ ..:.. ..::.. ..._.; ::..5'ZAddrea a 1 cert fy Nor I h rtvd th pylic f d t¢that N ebo a information is
.]egreq topomply.with ell city and county,ordinances.and memiewe,,uponding conntunion:and hcrtby emhodie rtprcumetives or Nii citymemer uponovcmemioned property for inspemion pdrpoxx.,,. .,(We)egieemsae indemnify arM keep hunileaS the Cly (C pen no eemda 1 dgmene. osu end expenses h ch may in eny y eccme against sa,dt..3z �nseque ce of Ne gra ung of Iht Perron-C TpL1JADERSTANDS AND WILL COMPLY WITH AtiL NON'P(iINP�. Issued by: Date
\� 1l n pp anVC facto 1} e�HAZARDOUS MATERIALS DISCLOSURE tWill the 12am r f t rc bu IJ
,pP , \ 1 Ia, n9a1rt+� e rohe at vmeal 1 Type,{ f a s3Oha
fs Roof
O�F+
a1 dened by theC penmo Municipal Coil,Chapter 9 12.and theHealth and Safety �Cad'Sec 2;{32(e)7 '
0year ori aItS All roofs shall speinced Cp"oi or Itoh 1a{ny roofin.�g,m.- aterial-being installed.,
",,Will the. pplie occupant _
._
but c pant use egapm ni de.ccs which If a roof is installed without first obtainin am ins ectlon,'lia ree to remove
ern hrz" ioas air ente
contaminants as dd by NAre.An Qu
e Bay Arality Management g P g
District?
- - all new materials for inspection. Applicant understands and will comply with
all'non=point sourceiegulauons
iha h nerd maian.1,regmrtmems oneerchepter fi95 of the -
Cabfomm Health&Safety Coda SBtiona 25505.15533 and 25534:],understand the,
fphebldI cscoca Qtlyha cote
.ocean t f 0 r quir ro t which mus,be me,prior to issuance f a Sqn fate of
p y , t.. ..
"` ] Signature of Applicant _ Date
I
No sae-eg m _ Z All roof coverings to be Class B"or better
-
t OFFICE-. ..____._ .. .. _. ._ ...