00080176 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI'Y NO,
OWNHR'SNAi NORTHRIDGE SG APPLICATION Still DATE
OA/PLF/ 01710
PHONEIS'AFAMITRA H _ v SANITARY NO. CONIROL NO,
'
a ce0 ARCIII'I ECUENGINEER: d J— - BUILDING FERMIr INFO
K F BLDG FLEC1I'LUMB MECH
v<6 IJ C=1 1 __J I_7
�7 LICENSED CONTRACTOR'S DECLARATION .lob Description
FN^
C z I hereby affirm that I m licensed under provisions of Chapter 9(commencing P
` sviaM1 Section 7llW)n(Dmenm J, tla ltucincaa an,LL�ofndone Calc.and my license
2,1 _ isunJe
infullform "
c a Li"°>e slut Lm.» L REF LACE 40 GAL. WATERHEATER
a o, Dale (�1 cnmtaaa
LL RCIII'11:C1"S OE abl
w
°� I audcr,mal my p un,.n;dl rte am.a1 ns panda nw�
c. a hicmmseA I'rolcsvionul
c.b—,O OWNER,1clean,I I DEC,Cone ION �J//OBJ
1 brrchy Idfirm thm 1 am exemn,trio Ina Cnmr.I,Co e.cense Law for my V
fY,'(,-C Iillich r8 comma,(Section]onsm Husinevc and vet de o demolish,
h,or:Any city or county
al x O which requires a permit m ronslme,,uher.improve,demolish,tar repair any efrvcmre -
ei pall to its issuance.idem quims,he applicant for Such permitto file a signed smmnxm
ei that he i.licensed pursuant tothe pnwi.inn.of the ClmfmmorsLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division J of the Business and Profession.Cam)
or that he i%exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subject the applicant to o civil pinnmrmnrethanfvehundreddoBat(S500) APN Number Occup:utcy ype
❑1,its owner of me prnperry.,Iny ettNoyce,will wage.o,their.nloemnp.,n.wion.
will in nae work.and the structure to tan Intended or offered for,ale(see,7044' 31.636 .
Ha,ies ami Pms:rr,sn,na code:q Ime caammtarwrx IHa'nsc Low de,nut;ytply m Ins aired Inspections
m'paoprny Who builds n tines Ia4 anwbn aw
hemd drsuch wad t
ltinell
orslhruugh Lad own,inpinycen.provided title web lm,n,bancm,arc nal intended or
o lemd for sal,.If.bass esrr,the Within,or improvenmon is sold vamt one year of 106 — SEWER B• WATER
completion.the omnerhuilder will hive the burden of proving that he did no,build or
mprove fm part mf,A,L 202 — UNDERFLOOR LUMBINGG
❑Laxmore,of hepmperty.amexciusivelyennttactingwith licensed enmmaot.m 301 — ROUGH PLUMBING
convrve the project(Sec.](liA,Resines,and Professions Cale)The Centracmr'x
License Law deals urn apply to an owner of property who builds or improve.thereon, 302 — TUS & OR SHOWER
and who contract,for such project,with a comraetoa,)licensed pursuant to the FINAL PLUMBING ENERGY
comano,License Law. 502 —
GIamaxcmp,anderSee, .B A P C for this rea,on 506 — GAS TEST
(Sur WORK[R'SCOMI'fNSA'I'IONDECLARATION 507 — FINAL PLUMBING
1 hc¢hy affair under penally of Ice jury one ill the following declurmionw.
❑ 1 have and will and main a Cenifirn¢ nl Cnnsem m ,ell=inwre for Weaker',
Compensation, as provided for by Section 37110 of the Lubar Cade, door ,be
ry : ,ante of the x'orA for wbicM1 this Mnnil is issued.
J 1 bale sink will nminmin W'orker's Cnngtenution Insurance,as required by Sce,ion
Ip of,he Irbur Calc,liar the perhtnnance of rhe work for which This permit it
iss ted.(�t�y�WtoQrker�,C�mplenLs�tion Inwrence carrier unJ Policy numMr arc:
C arm,
OU
PE1 ESHMPn(1NRANC WORKERS'
COMI'IeNSRI'IUN INSl112ANCE
[Thi,xcc,ien need no,he con,det,d it the panni,is fortune hum lmd dollars
1411101)nr Ic.,1
1 of ify thea m the"Immonce of the work for which,his Penni,is issued,1
,hall not employ any person in any manner so as to become subject to,he Worker%'
Compensation Laws of California,Data
Applicant
NOTICE TO APPLICANT.If,alter making this Certificate of Exemption,you should
become subject in the Worker's Cmpensation provisions of Ne Labor Calc,you must
Q 0 forthwith comply with such pnsfor ,nr This permit shall he JeemeJ revoked.
FCONS1 RUCIlON 1,17NUI NO AGENCY
I hereby aHlrm,hat[here is it concmer on Irish ng agency for the pe'lonn:mce
of the week for which this perp it is issued(Sec.3897,Co,.C.)
Q Lander',Num,
a Z Lenl,-looldre,c
U C 1 centry that I have.cad 0i,application and slide that the abase infa...In la
4. F, comet.1 u,evc m comply with all city ad ,only mdinunce,and.care laws relating
O m+lwildin,—voland b
hereby au, nrim rcpresenmmpon
,iosl of this city e mer u
�] the aMrvcmen,iould property for inspection purpose,.
E}' g (We).,me m save.indemnify and keep bmmles the City of Cupcminn against
lin liabilities.judgments,coats and expense,which may in any way aortic against said
V Z City in clone Glace of fhe gmming if dr,permh. . �T f ,,r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date U l`Lf
SOURCE REGULATIONS.
Signature m'AppliroaliContmcho Da,o Re-roofs
HAZARDOUS MA117RIALS DISCLOSURE
Will Icappbeatt or rmare nnudlug ocnpmn swan o
. r handle hueanlam mloultral Type of Roof
tax defined by the Caperdmt Mari Code.Claim,9.12.rod cite ueal,h land Solely .
Calc. ❑Yrot 25532(x)'! 0 N
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or home holding occupant use equipment nr device,which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit homeless air contaminants u.,defined by the Hay Arca Air Quality Management
DistrictI all new materials for inspection. Applicant understands and will comply with
❑Ye, 0 N all non-point source regulations.
have read the hac,ohn,materials requirements under Chapter 695 of the '
Ca illons Hcahh es Safety Cole,Section,25505,25533 mal I understand that
Jrtholhouldir,doo,tralcourrour rose a Il l bar It is my re,pnmihil by mu nodi lY the
man of the rrquircmer s oto must x met prior m ac,uonce or a eesdfirme of
i Date
���� Signature ofApplicunt
I)..".Houma , Dam All roof coverings to be Class "B" or better