03010089 CITY OF CUPEwrINO »fix=, � � , .- J
BUILDING DIVISION PERMIT COW, T' ORIINFORMATION n
BUILDING ADDRESS: LOPES ELECTRIC INC PERMIT NO.
21782 LINDY LN 03010089
OWNER'S NAME: _ 1060 ELM SSI` APPLICATION SUB DATE.
SAN JOSE WATER CO. 01/15/2003
IIONE: —T-4—o-8984-8422 SANITARY NO. CONTROL NO.
ARCIII'FECI'/E:NC.INEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MP,CII
0 0 0 0
�OpLICENSED tNSEDCONnRACTOR'g DECLARATION
P Ihereby )),,f Ihm1amfMeBdunderpr Pofeax of.Chapter Code. 9ne,beensci, Job Description
u
with eminn 71NN11 of UivisiunJnf Ne Business and Prufexsiom Coble.and myliccnm is ,
ullforecandcloc �Y �'y�7)�/� CHANGE OUT SERVICE �rfRRp�kTyt y fT
zopn_
License slats kN
—Uc.xctor— pf (PUMP STATION) �r""�y,�,p�a"!'1
pypasewe Contractor— �aA
F- ARCHITECTS DECLARATION "+
1 understand my plans shall be used as public recordsV,` FE& 1 2 2003
F LL LLO Licensed Professional
g Oat I am exempt
from
DECLARATION
�s�<Y I hereby affirm that I am exempt from the Contractor's License Law for la
p0 following reason.(Section 7031.5,Business and Professions Code:Any city or county U'LDING
x m� which requires a permit to construct,alter,improve.demolish,or repair any nactue 1 JI
'o
on pme,It,it,issuance,also requires the applicant for such Pmmit to rile a signed statement
'hat he is licensed pursuant to the provisions of(be Convutor's Lice rise Law(Chapter 9 Sq. Ft.Floor Area Valuation
y�0 (commencing with Section 7gaBof Division 3ot Ne Businessand Professions Code)or $800
y $
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
ammmeln..fivehnnmeddollars(s5w). 35624025 . 00 P y yp
❑I,us owner of the motherly,or my employees with wages as their site compensation,
will du the work,and the structure is not intended or offered for Sale(Sec.VIN<,Business
and Professions Code:The Convectors License Law ones not apply m an owner of 103 — UFER Required Inspections
property who builds or improves thereon.and who does such work himself or through his
own employees.provided that Such improvements amenot intended or offered for sale.If, 304 - ROUGH ELECTRICAL
however,the building or improvement IS sold within one year of completion.the maat towner- SOS - FINAL ELECTRICAL
builder will nam the human of proving No did nor build or impmw for purpose of
ssla.).
❑1,as owner of the progeny,am exclusively contracting with licensed contractors to
construct the project(See.7064,Business and Professions Code:)The Conlsacmrs LE. .
cense law does not apply to an owner of property who builds or improves Memon,and,
who contacts for such projects with a contractons)licensed personal to Ne Contractor's
License Law.
I sen exempt under Sec. ,B&P C for this reason
Owner Data
7C37CWORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one or the following declarations:
❑I have and will maintain aCeniricateaf Consent roself-imumforWoder'sCon,en-
0
ation,as provided for by Section 37M of the Labor Code,for the performance of the
ork for which his permit is issued
I have and will maintain Worker's Compensation Insurance,as rcyuired by Section
Xof Ne Labor Code.for Ne Performance of the work for which this permit is issued.
My Worker's umpe cation Insurance carrier and Polic ere:
anicr:� / l=ag2 Policy No.: u
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not w completed if the permil is furore hundred della.($IM)
or less.
1 certify that in the Performance of the work for which this permit is issued,I shall not
employ any person in any manner vs as to become subject to the Wmkeri Compensation
Law,of California.Date
Appricanl
NOTICE TO APPLICANT:If,after making this Cenilicate of Exemption,you should
Mvomc subject o the Worker's Compenatlon provision,of the labor Code,you most
O O forthwith comply with such pmvinmo or this Kninil shall be deeseed levnked.
zCONSTRUCTION LENDING AGENCY
[-+� I hereby affirm that there is a construction lending agency lin the Performance of
Ci the work for which this permi t is issued(Sec.3119],Cis.C.)
�W Q Lender's Name
z Lender's Address
U Q I cenify that 1 have read this application and sum Marine No.information is
collect.I agree to comply with all city and county ordinances and state laws relating to
0U building construction.and hereby authoris repmsentatives ofthis city to enter upon be
;t- {!] xbovcmenlioned potbelly for inspection purposes.
C (We)agree m save,indemnify and keep harmless the City of Cutonino against
r (,I liabilities,judgment,costs and expenses which may in scenic.&.,all said City /`�2
(J z mconse c of the 6raming of this permit. -f-
30
•^ APPL Am'UNDE NDS D WILL PL rof ALL NON-POINT Issued by: D e'
SO CE REGU S.
Re-roofs
n aonc o' cunJComannr Dam
IIA%ARUOU ATERIALS DISCLOSURE
Type of Roof
!
Will Ne applicant In'ful building oceupanl store or handle ha,moous material
as defined by the Cuprni M.nio,l Ne,Chapter 9.12,and the Ileahh and Safely
code, 0W,2ss32fan�I,
fortune
All roofs shall be inspected prior to any roofing material being installed.
❑tion
Will the applican furore btuWin ant use cyuipnmm or Jeviccs which If a roof is installed without first obtaining an inspection, I agree to remove
emit to 'dons...e..rium an I,as d dhy the Bay Arca Air Quality Management all new materials for inspection. ;
District
Yes
I have(cad the Nous maunals requirem uunarChaPurfi 95of the Califnr-
riafiealN&SafclYCsxk.Sxdons 255115.25537 514.1 unarsurud thmi(Ihc building
dop`Some mly ham n unanl,that' 's mihiliry m nndfy tM uecupent of tM -
4Yire ntswh7chin elp tom cenftic'n;riaterfoccupons, Signature of Applicant Date
o ar..mmi,e ger( Date All roof coverings to be Class "B"or better