03010047 CITY OF CUPERTIN0
BUILDING DIVISION PERMIT %CONTRACTOR INFORMATION
a „rte.
BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO.
1043 NOVEMBER DR 03010047
OWNER'S NAME: 10297 S DE ANZA BLV APPLICATION SUB DATE
JIM PIERCE 01/08/2003
orONE (408) 253-0618 SANITARY NO. CONTROL NO.
ARCHITECTIENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECU
0 0 0 0
1-00 LICENSED CONTRACTOR'SDECLARA330N JobDescri Description
0 1 herchy M.that I am licensed anile!provisions of Chapter,9(commencing p
with Section 70(Xh M Division 3 of the Business and Professions Code,and my license is
n, in full force and effect.
zpla4 icensne1aas 1= Lie.« ? 9x5 REPIPE/WATER SERVICE .
pZF❑ Dale Con r G' Uwr
/t /� rRCHITR LAc ION
3 and ,y wsh use public reinrd xl W! Leel
P
nsc [essmnal
OWNER-BUB ER DE ATION JUN 5 Zp9
I hereby affirm that 1 am ca pt from me Comramnr's Liccnsc Lew for Ibe OJ
a60O fall me reavm.(Settion 7031.5,Business and Pmfessimu Gavle:Any city or county
%$ which myuires a pctmit m csmswct,allot improve,demolish,m repair any stmcum,
w�'^
poor its issuance,also"itires the applicant lot such Permit file a signed statement
that beislicensed pursuanItoNeprovisions ofthe Comractir's License Law(Chapter 9 Sq. Ft. Floor Area $5 Mi4tion
(commencing with Section 7(100)of Division 3 of the Business and Profensinns Code)or
Nat he u exempt mcrefrom and the baso for me alleged exemption.My violation of
Section 7031.5 by any applicantfor apomit subjects the applicanuo a civil penally of Occupancy
not mom Bun low hundred dollars(M). P y Type
❑Lo due
work.
the pm perty,mmyemntendedwBmfemd for We(Sm.compensation,
will domewon.and the structureisLtdedn La.does not apply on an Business —
bNIDE
and Prty wh ooa Code:The Comractots License Law uch not apply lf an owner of 301 - ROUGH gcc IODS
propertywho buildsorimproves himpr andwho doessuch work himselfsermmake his
ownemployena,ping or imrwchimpforcmenuarene year of C mpletired Intake. SO2 - FINAL PLUMBING ENERGY
bowercO me building or len of proving
is mod within one year of completion,me nwner-
.It.).r ,will have Be burden of proving ten he did not build or improve for puryax of 507 - FINAL PLUMBING
La'
❑1.as owner of me property.am eaclmively eonuaning with licensed Contract..m
construct dm project(Sec.70x4,Business and Professions Code:)The Contwurr's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contraca for such projects with a camranor(s)licensed pursuant to me ConhaemrS
License law.
❑1 and exempt under Sec. ,B&P C for Nis reason
Owner Date
WORKER'S COMPENSATION DECLARATION a
1 hereby afro under penally of perjury one of the following deelaritions:
I have and will maintain a Certificate of Consent to self-imum for Worker's Compen-
sation as provided for by Section 3700 of Ne ocean,Code.for Ore performance of the
work for which this Permit is issued.
have and will maintain Worker's Compensation Insurance,as reyvirtd by Scpion
Of the LOMr Code,for rot performance of the work for which this Permit is batted.
My Worker's ComPensadon Insurance carrier and Policy number xre:
Cartier: _ 7; 1-VSJ°7 Policy No.:471't,01 VNI TOS ocr
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section outdoor Mmmpleted if me pannio is!iron hundred dollars(SI0)
or Ices.)
1 cenify mal in the performance or the work for which Lis permit is issued,I shall not
employ any person in any manner an as m become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE;TO APPLICANT:11,after making this Ceniricate of Exemption,you should
become subject to me Workers Compensation provisions of the IaMu Code,you must
OO forthwith comply with such provisions or this permit shall he deemed revoked.
z 0 CONSTRUCTION LENDING AGENCY
P I [Ohereby Whichthi commit i isaed(Sectinn lending agency for the performance of
a me work fur which this permit is issued(See.3097,Co.C.)
Q Lender's Name
z Lender's Address
U 1 certify mat 1 hats read this application and stem mm be above information is
w F- connect.l agree to comply With all city and county ordinances and wise laws relmingto
OU building conswNun,and hereby aummim rtO OtAti.of this city te color urym lbe
r above-mentioned property for inspection purposes.
(We)agree In save,indemnify and keep harmle me City of Cupertino agdoul
LE"y y liubilities.judgmenu,cusuandexpemtawhicpmayi the
way accme against said City
U Z in const uence of granting of mis form'
^� APPLICAfjT U ERSTANIS AND LLC PLY 1 ALL NON-POINT' Issued by: Dale
(za
SOURCE EA O
�< '0 3Re-roofs
S19.4111111(5f
ApplicantiCtudi cur Date
HAZARDOUSSCLOSURE Type Of Roof
Will the applicant or future building occupant stem or handle haeamous material
as defined by the Cupenino Municipal Gde,Chapter 9.12,and the Health and Safety
Code.Satins 255320°7
❑Yrs pf No c� All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building..Pont ave cyvipmcm nrdevices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hamrdous air contamimnu as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
/.
the Orap hares ausma rials uimmenudc
unr Chapter6.9Sofmc Califon
nice1h, affil ak. voce ,2 33and255.3a.lundersmndmmiflMbuilding
docs n I have 'it. ad is y respmsihilit lu+mtify the occupant of the
"un n ic t a fieae f v ancyo Signature of Applicant Date
Owner lnod'rcda m Oart- All roof coverings to he Class"B"or better