04040067CITY OF CUPERTINO
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IE0RYAATIOL\:
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
FISCHER PLUMBING & CONST
PERMIT NO, 04040067
-' ER'S NAME:
PERMITISSUEDATE
ILLOYED YAMADA
2766 SCOTT RT'Nl-)
n4/i2/2oo4
.JNE:
SANITARY NO. CONTROL NO.
(408)727-2426
ARCHITECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
I hereby efrom that am licensed antl visions of, 9 (commencing
E�o11 p p RA0
Job Descrlptl0nmgl1M Ny5 L ®
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Cmde.
with Scnion]IXXq nc Oivixion3of the Busjnc IProfcssinnx Cndc. antl my license is
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`nicicnlumsb,gpflerrect. 3L 3 35L1z/
REPAIR MS BATHROOM
�1. Cmur e
iia - -o comm/_ �r.�r
NEW TILE/PLUMBING FIXTURE MAY 13` 2004
ARCHITECTS Da TION
1 understand my plans shall he used as public records
BUILDING
Licensed Professional
OWNER -BUILDER DECLARATION
1 tachy .Nero than am exempt (rani the Cnnlnclnrs Law for my
e: Any
massa. Code: Any tiny nr county
]1131.5, Business andprofessionsimprove
follwhich
demolish, or mash any Structure
which requires a permit deori
Gonia I construct, alma nt
prior its issuance. re for such ned Law (Chapter
to inion Of for Contractor's le a
Icor lh.pmvisionsofthe
the
Sq. FL Floor Area
Valu ipr�000
pursuant provisions
oftCnntuclar'aLicenseLaw(Chapmr9
(commencing wiit Section? Cndc) or
al Business and
basisofrth on. Any vi
'Nen he is exempt therefrom end Ne baso for the alleged exemption. Any vi.Imlon of
empt therefrom and) the
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not mare Nan five hundred dollars ($50B.
31639029.00
❑ 1, ns owner octhe properly, are my employccs with wages u their sole compcnsatinn,
Required Inspections
will do the work, and the suuomm is not intended oroffen0 For sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who doessuch work himselfor through his
own employees, provided Nm such improvements arc not Intended .,offered for sale. If,
'
however, the building or improvement is sold within one year of completion, the.wncr-
builder will have the burden of proving that he did net build or improve for purpose of
sale.).
❑ 1, as owner of Ne property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense law dues not apply to an owner of property who builds or improves daemon, and ,
-
who contricu for such projects with a contractor(s) licensed pursuant to Ne Contract.(.
License Law. - -
❑Iamexemptunder Sec. ,B& P C for this reason
m.r Date
WORKER'S COMPENSATION DECLARATION
1 hereby affum under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenificate of Consent to self -insure for Worker's Compcm
sation, m provided for by Section 3100 of the labor Code, for On Performance of the
work for which this permit is issued.
❑ 1 bane and will maintain Worker's Compensation Insurance, es mquind by Sectio
377 of the Labor Code, for the performance of Ne work for which this permit is issued.
My Wmkcrs (n�P�ens/yn Inmmnce carrier and Pn' n herare:
C 1 ss/a, S� Policy N Jy,
,CERTIFICATE OF EXEMPfIONF OMWORKERS'
COMPENSATION INSURANCE _O
(This xelinn need nonce c.mplcmd ifthe permit is for one It bred dolls s (51(X1)
.f Ins.)
1 certify that in the Performance of the work for which thi4permh is issued, I shall not
employ any person in any m tar nerm m to became subject to the Woderd Compensation
Laws of California. Dam
Applicant
r
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall he deemed revoker.
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CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construcdnn lending agency far the perturmance of
be work fur which Nis permit is issued (Sec. 305], Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read his application and sum that the above ofommnion is
correct. I .,me to comply with all city and county oNinances and sum laws relating to
building eo earaction, and hereby amhorin representatives of this city to enter upon the
above-memioncd pmpeny for inspection purposes.
(Wc) agree to save, indemnify and keep harmlcas the City of Cupertino against
a.
liabllities,judgmenu.eosu and expenses which may in any way acerae against said City
in consequence of the granting of this Permit.
/
APPLICANT UNDERSTANV ANg WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGU TIONS.
Re -roofs
Type of Roof
Si star.. App icarocontr tar Dam
HAZARDOUS MATERIALS DISCLOSU
Will the applicant or future builJin dupanlemre nr M1endlc hazardous material
az deBncd by the Cupeninn Municr'nps de, Chapter 9,12, and the Health and Safety
ode, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment of device, which
emit hazardous air ..alumina; az def y the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Ycs11
I have mad the bmallouarmanials requirements under Chapter 695 Orem Califm.
nia Health& Surcty Codc. Secuons 5505.25533 and 25534.1 understand dedifthe building
docs not currently havejt was. aid is my respansihility Itdfy Ili. occupant of the
require m.nts .ieh nor at issuance.face mli.a" Qcupancy
o�(
Signature Of Applicant - Date
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All roof coverings to be Class "B" or better
mer
or aath.rived agent Date