01020013 CITU OF CUPERTINO
BUIIAMNG DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
51914 nin TOWN CT CUPERTINO PLUMBING 01020013
OWNEWS NAME: APPLICATION SUB DAL li
BL 02/05/2001
I'tlONli: SANITARY No. CONI ROL.NO.
Qa0 ZO ARCIIII FMAiNGINEIi It', BUILDING PERMIT INPO
_ IA.DG BLOC, PLUM MECH
FN-zw IJ 1=3 LJ
OLICENSED CONTRACTOR'S DECLARATION Job Description
f2' I hereby affirm that Ins licensed ander movisiort of Chapw 9 tcommencmg
with Sevtion](XX))n Dni lot the itusinery and provisions Coda and nay Iwrote
is in full force nn I Liv -
�z�a 11.1c cora, �' Lm.x �yi O COPPER REPIPE & WATER SERVICE
3 LL O Datta�X-4 q DECI.,nr�f1
F c,Ori, plans
II Iti use as public
ti
g I unJcmmnJ my Plains mull h used as puM1lic ren,Ns
r�
l icunscd Prvfawionnl
is o OWN17R 1tU11.UER DECLARATION
1 hereby affirm that 1 am exempt Bim the Cmicar air's License law for the
C?j C fullowing moron.sen n17031 5,Ba,lac,,and I'mfc,in s Crkle:Any city arcnntoy
L FY_-Co which routines a permit Y,enuttuc6:dter,intpmve,demolish,tit repair any imic ure
7
prior it,its .. Lso onquiresthe applicantfor such knout file & d.r¢mens
d%=
thdi he is licensed pt top f he Contractors 1 I (Chapter9 Sq. Ft. Floor Area Valuation
(conuaig w'Ih Svuon 7001ool D'v6t,3W he Bus'u dl- Iv,d nsCnto)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation 190 out
of Scainn 7071.5 by any applicant for a permit subjeaS the applicant to a civil penalty
of nioemanlive Inmlreddouar,(esw). APN Number Occupancy Type
❑I,as owner of the prupcny,or my employees with wages as their aide compensation.
will do the work,and the structure is not intended or offered fir sale(see.7044. Required Inspections
Bus and I'nd'ex n Colac
e:rhe conftors Liocn.w law doe,not apply to a e q P
vner of pmpcny Who builds or improves thereon,and who dans such work himself
or thmugh his own employees.provWcd that inch improvements are not intended or 202 — UNDERFLOOR PLUMBING
ofl'uted for mlo.IL hnwuvcl the hudding or io stamen IS sold within one yah of
completion.the owner Wilder will have the burden of proving that he did not build or 301 — ROUGH PLUMBING
imp,ove rat pagmse tf sale.).
❑I,as owner of the property.all,esdusivcly enmmamg with Licensed contractors to 502 — FINAL PLUMB INS ENERGY
instruct the project(Se.7044,Business and 1'mfrvoom Code:)The Coanmcbr s 507 — FINAL PLUMB I NG
License I,aho
w docs not apply ,in owner f promny who builds or improves thereon,
and who conaaas for,sad,projects with h contrualmU) Ilccmed pursuant in the
Contractors License Iain. '
❑I un,exempt under Sec. .B k P C for this reason
Owner Date
WORKER'S COMPENSATION DRCI.ARATION
1 hcrchy ratio,undo,pamlty of perjury ono of the following deel"nous s,
❑ 1 have and rill maintain a Ceniricate Lir Coment to clf-inmre for Woder's (/
C.... in,aion, nos putvidcd I'or by Smtion 1701 it the I.ahm Cock, roc the O/
perhmnanee of the work for which his rearm,is issued.
❑1 bore and will u,notdo W..ker'n compensation Imnmner,as squired by Scainn
971X1 of the lawn Code,for the peri nni nce of the work for which This permit Is J
I,sY it h1Y W it ` Co nsution++ lirr� tort ..it Policy n ber ate:
C.—I.—.,. MKtf1�FyNo,tW07030V
CERTIFICATION OP EXEMPT[ON FROM WORKERS'
COMPENSATIONINSURANCE
This section need not be completed I the permit 6 for one hundred dollars
(5101)in less)
I«n lfy that tit the performance of the work for which Ibis wnnit is Noted.1
shall not employ any person in any turner so as to become subject u,the Worker'
Congxmsation laws of California.Moe
Applieum
NOTICE TO APPI.ICANT:If,after making this Certificate nl lixcmpfinn,you should
become subject to the Workers Com,cnwtion provisions of he Ial,or Code,you toast
O tunhwiah conq,ly wllh sacs provisions air Iles p:onil droll W deemed revoked.
z _
^F ^ CONS'1'RUM]ON LENDING AGENCY -
aiI hereby affirm that there is a conamed i lending agency lr ithe performance
of the work In,which this permit is issued(Scc.3LY4 Civ.C,)
Q I<nder's Name
5 z Lcndcr's Address
V O 1 citify that I have read this application and state that the above Infatuation is
t.. comet.1 agree to comply with all city and county ordinances and store laws relating
O �) n,Indio ngconstmmlun,and hcrcnymihorl.e repmsentallves of his city to one ulxm
he aN,ve.nnclu ned property lin inspersion pugr,scs.
f' a. List attract,to save.indemnify and keep harmless the City of Common against
y II', 'io.ludgmers, 'If,and eapcn.es whmh may in tiny wuy'areme against said
V T ..y in cmnseque sof c pouting of his pcnnia.
s�l'I c I' NI tR ' 1NDS ANUWOMPLY wy{dfn INT Issued by: (1Date
Signature of AI Iicantleoa actor '' O[ Dare Re-roofs
HA7A R)USMAIERIAISDISCI.OSURT
Will he alt,, . (or ralnrc nodding uavpfnnt nom m Intmd,e nn,a.has m:niial 'Type of Roof
m dcfn,d by the Cupenino Municipal Cmlc,Cltopmr 9.I2.:nnl the H,rdlh tin I laldy
Cala Section 25572(a)'!
DYE' 0N All roofs shall be inspected prior to any roofing material being installed.
Will he apPheanlmFuture baildiii,ce, rnsa,aa,unpotcatgrdative,which If a roof is installed without first obtaining an inspection, I agree to remove
emit ha,ardous air imtamitnnts as defined by he Bay Area Air Quality Management
Dlw;cfl all new materials for inspection. Applicant understands and will comply with
I Cl Yr, ElNo all non-point source regulations.
1 hove read the hnaanlons mm<ria,s requirements under Chapter 6.95 of the
Culifu 11,� Ilcdth k Suloty CoLe.Seelions 25505,25597 and 25574.1 understand Lobs
Sm
uiNing do sat ncndyhmcamnam.thm it is my rcsptmzibilityto notilythc
m air ht,, a u my which tonth,hat prior to issuance Orn Cmifietim ofcy`� r. � Signature of Applicant Date
ower n,:anamorncol:,gv Dore( All roof coverings to be Class •'B•• or better
OFFICE