00090031 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RIHLDING ADDRCSS: PHRMI'I NO.
OWNER'S NAME: APPLICATION S(IB DAPI?
1 1713:71 PHONE. - _ SANITARY NO. CONTROL No
0 17114/OR 1PIAL&A
n al y ARC]I N
I'I'ECT/I: ...h -NAl AVE BUILDING PVRMl'I'INFO
�02IfLUG ELECTPLUMS MECH
�G O —
FHj LICHNSEDCON'I'RACI'OR'SOIiCLARATION Job Description
Dyy m C I herby afrnn Dant 1 uln rcanrnl mode,Fravisian5 of Cb:yner v(n,mmenchty
f,=C� with Secrion 910X)of Uivinion 3 of the B.,ine,malppool .�....as Gslc.antl Illy l iccnm
R: �! ix Tense (lace any( c1. fes— Lic.a yi� -✓��
O n U Date Cls./._(/ l7 1
�- Date q!$�00 Contrast"D, I11 �+ t\
s a I ARcnrrrcf•s n1iLNyp11 1. 7
F ry O 4 1 an lerxmnd my pinn,shall be tactics o1h,recnrda
REPLACE WATERHEATER . 'y/
u,a O Licensed Professional
OWNER-If UILDIIR DECLARATION
v. I herby affirm that 1 am exenmpl fmm the Canducho License law for the -
1_�i foldwing reason.(Section 7031.5,Business tad Profession.Curia:Any city.,county - `J
S O witch myuirn a relor In mmurmt.:1111,,improve,detnolinh,nr«pair any.mature
i3� priorm its isauaum•uho requires thu applicant ldn
basuch lemo fife a signed.stmenenl
that he inlicensed pursuant Ill provisions.ftheComomtor',Li«d-Lave hChimt,ar9 Sq. Ft. Floor Area Valuation
(commer¢ing with Section IDO(p of Division 3w`the business and Profession,Code)
or that he is exempt therefrom and the basis for the alleged eacmplian.Any violation
of Section 9031.5 by any applicant lora pllmdl subjects the applicant m a civil penally
of in..cthanEabtndreddoll,,,,(S500), APN Number Occupancy Type
01.a owns of IFe property.at my employees with wages as their side mmpensauon.
will do the work,and the structure is not intended or offered for sale(Sec.70o. �+
Required Inspections
Business and professions Code:The Contractors Lieense La ares not apply am an
r of pre,eny Who builds or inqumcs there.n.and who doer such work himself
owner
ough his owo ca ph"res.proemed that.am oullo,emerns are aa,imetmded or
oRend far sale.IT Ill the badifing Lir improvement N slid within one year(if
completion,the owma,builder will have the burden of proving that he did not build or
improve for pappose mfid..),
❑],;Is owner of the aopany.ame.claavely, eonlracting with licersed contactors to . 106 — SEWER & WATER
Lma9al the pooNO tree.7044,Ha,hat,and rtofenrtma,eadef The Coilmeio 1 202 UNDERFLOOR PLUMBING
icense Law does not apply w an owner of pmleny who build.or Improves theism,
and who contracts tar such projects with a central licensed pursuant m the 301 — ROUGH PLUMBING
Comr:atoes License Law.
o?tun etempt Israel See. .H k P C for this realm 302 — TUB & OR SHOWER
Owner Date 502 — FINAL PLUMBING ENERGY
WORKER'S COMPENSATION DECLANAIION
506 — GAS TEST
• I hereby anima under penalty of perjury ane of the following declamtirt
❑ 1 nava cad will mbmmm o Canineate of C...vot to self-theme for Warkerr 507 —
FINAL PLUMBING
Can.pcnsntion, as provided Rrr by Semiun 90111) of the Labor Code, lin the
performance of the work for which this permit is issued.
01 have and will maintain Worker*,,Compmnalion Insurance,s required by Section `
37161 of the Labor Code,lot the perl'annanee of the work for which this Isermit is
.sued.�.M1yAWvorrkkrer's�C�onrpcnwminn Insurance carrier and
policy number are:
tNW[.LIAL.hL—PulicYNou: 0{,{�yIIE AI'l_
CER IICATION OPIiXEMFsh, .EROAf f h
COMPENSATION INSURANCE
fade section nmd not be completed if the lwmmit is farm,laralred dolbts
(S10lH as less.)
I certify that in me perfornonee ofthe work for which this permit is isacd.I
shall not employ any person in any manner so as m become subject to the W arker,'
Compensation Laws of California.Uwe
Applictmt
N(A CE 10 APPLICAN 1:lf:after making Ibis Cenif inac of aar,atn oa.you should
become subject m the Winkcls Compemsmian provisions of the LuMo Code,you most
Q 2 forthwith comply with such provisions or this permit Mall be deemed revoked.
CONSTRUCT ION LENDING AGENCY
I hereby nllimm that those is a crnelorian 1111,11111 1111111 for the perfomemce ,
of the work for which this pmmit is issued(Sec 3007.Cis.C.)
LLender's Name
Z lender's Address
V 1 cenify find I have read this appirea ret and state that the above infonnation is
co sect,I agree ,,mayfly wins all shy and anonly nourrace. nal state laws relating
V In balding construction,and harchyarthoree rejae.cmmocs or this city tu enwrurym
} W the aMw'e-mentioned pngseny for inspection purposes.
t„t p. (We)agree In sav,indemnify and keep hamdess the City of Cupcnin,against
Vi liabilities,judgments.costs and expenses whmh may in any way accrue against said
V z C'uy in conw,mme rf the smndrt, It his pencil.
r APPLIC NDERSTANUS A WILL COMPLY WITH ALL NO MINT Issued by: Date.
SD RC RE d S �/p V
Sig tmre.L l t/ L11 Dafe Re-roofs
HAZA sac lit"-T\LS DISCLOSURE
Will meappneam ar Marc mdldlng reeapnda aore armmdle harrmoer laudal Type of Roof
u'Ielincd by me Cupertino Municipal Code Chapter 9.12,Intl the 11,1111—old Safety
Cole.Section 2553210?
0 Yes 0N All roofs Shall be inspected prior to any roofing material being installed.
Will lhermliscat.rmmrebtndirloemprmt.,aor,mmtentordevice,which If a roof is installed without first obtaining an inspection. I agree to remove
our hueunlom un—lmminnms o defined by oho pay Area Nr coldly Mnnagmnunt
District? all new materials for inspection. Applicant understands and will comply with
0 Yes 0Nn all non-point source regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health k Safely Coals,Stearns 2550 155)3 rmA 25534.1 undcrsnmA thin
if'the briding dos Bol cnncmly bac a mnmt,mal II is rry responsibility too....Iy m1
onal me mgmatuar ,wI' I nnnl be nmol Prior In isiumee.f a Cel Ikons of
Occu
it l C'r /O./I— Signature of Applicant Date
o ,m — X All roof coverings to be Class "B" or better