01090084 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
918 OLD TOWN CT CUPERTINO PLUMBING 01090084
OWNER'S NAME: APPLICATION SUB DATE
FULLERTON JAMES R AND MAUREE 10297 S DE ANZA BLV 09/20/2001
'HONE: SANfTARY NO. CONTROL NO.
(408),253-0618
9 C o ARCHITECT/ENGINEER: BUILDING PERMIT INFO
Kz u- BLDG ELECT PLUMB MECH
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Z LICENSED CONTRACTOR'S DECLARATION Job Description
Iherebyaffirm ant Iam.fheBundo Ind Profess n,mpwr9(driceing
5N withfalmn9W0) fDivision3ofrheBusinessendProfessionsCWe, d n. REPIPE WATER SERVICE .
<x is infaRfine.nd Y On Tee FIl�AI.-E®
:I C a Littnse Class " 1 �O Lic.N
p y U Dan, 0. o f Comrcmr
uO AgCm_SCIS DECLARM N
st I undersand my plans shall be used as public records 0 C T 2 4 2001
int
i-p C Licensed Pmfexsional
OWNER-BUILDER DECLARATION
I hereby affirm that I sum exempt from the Contractor's License Law for the BUILDING
following reason.(Section 7031.5.Business and Professions Cade:Any city or country $5000
re F o which q permit w conawet alar improve,demolish or repair any strucwm
in
orm he is ficimtediptualairdroash pfansom of the Contractors nnse law(Chagcri) 1 g-�is ,�':J�a - - - -- - -
(commercingwth SaOnn 7")of Division 3 of the Business and Ryfesxionx Code) t.'C.- y�3,�0-r S.U:7"l-�-tai .,i.�,TI t3` Valuation
or that In is exempt therefrom and the basis for the alleged cfempoo.Any violation l
of Section 90314 by my applicant For a permit subjects aC spheral an a civil Marty -
of not nomadism five hundred dollars($5110). 10(1 P N�R & WATER i Occupancy Type
❑[,as owner a the Property,to in,employees with wages as their ,sole compensation.
will do the work,and the structure is not intended or offered for sale(Sec,70W4, t n
Business and Profusions Cade:The Contractor's License law does not apply to an 301 - ROUGH PSI&TdQspeetions
owner of property Wh"builds ar improves nbe scree and who tlw such work himself 302 - TUB & OR SHOWER,--
or through his own employees.provided that such improvements ate not intended ar
offered for-sale.If,however.the wilding car impmmarom is rola and.one year of 502 - FINAL PLUMBING NERGY .. . •'
iampktim,the ownenwllder will have the waren of proving thm he did not wile or
mproveforporwrenfalc.), 506 - GAS TEST
_.
01.,as owner of the property,ore exclusively d Prafeing do licensed eonracton to 507 - FINAL PLUMBING 1
icensenstruct the
oesatgappltoa owB.ner
and Professions Code:)The
vesContractors
License Law does two r such
to am ave w of property who wilds or improves t to do
.end who contracts for such projecrx with a conrractorts)licensed pursuant to die _ _ ... .. .i
Contractors License Law. r
❑Is.exempt under Sa: B&PCfor this rtawn
Owner i Date
xi WORKER'S COMPENSATION DECLARATION
I hereby ofhnn under,penalty of penury one of the following declarations:
❑ 1 have and will'r oimnin a Certificate of Consent 10 self-insure for Worker's
Compensation. as,provided for by Section 37W of the Labor Code, for the
_ perfotsna«e of the work for which this permit is issued.
❑1 have and will mal oado Worker's Comperstion Insurance,as required by Section
31!00 of the laver Code,for the performance of the wart f«which this permit is
issued My Workers_Compensation performance1 sura«e Cartier and Poly number
;
40 p.licy No./ �--y ! I 1
Crim a .. Polic3 KERS
a CERTIFICATION OF EXEMPTION FROM WqR
" " COMPENSATION INSURANCE "C" ' .._„._...... _ _ .. - __._.._ _......_.._,_
'innh sebtion heed ore be completed if the permit is for me hundred dollop 'I - ,x i i'•. lr
SIM).,less.)
I&reify that into dWg rmmance of the work fm which this remain is issaed.1, r n s)„1.0 it
"I not employ any,person in any manner to s �o become kubjest to the Workers
Compensation Laws o'Callfamm.Data
Applicant9 --
NOTICE TOAPPLICANT.If.dict making this Certificate of Exemption,you should
become subj&t to the Wdrker's Compensation provisions of the Labor Code,you mus
0 O forthwith comply with such provisions or this permit shell W deemed revoked.
z _._ - ..
1 _
F V) ” ' ° —CONSTRUCTION LENDING AGENCY,
work
kfor ch this nhcar is s con of(Seco lending agency for Ne perfornuntt ,
r
flatersNfor which Niapcimii is iupM(Sec.3097.Civ.CJ' I
W"Q [sender's Nnme. .. ... .... . .
:z Lender's Addmss I'I
V -. 1 unify 0.11 have read this application and sure that the above information is
W pm correct.1 agree to Comply with all city and county ordinances and state laws relating
0 C.1 In wilding comaraction:and hereby authorize apresenoatives of this city to enter upon
lam rhe move-mentioned property for inspection purposes.
,I ly (We)agree to save:indemnify and keep harmless the Co,of Cupertino against
m liabilities,judgments.costs and earcmes which may in any way accrue against and
Q z O onsequ<nce of the greening of this permit. "
SOPLC TI'U D,R. SNDSANDWILLCOMPLYWITH' LL NON-POINT Issued by: Date
stgnat rete A tractU gar= Re-roofs '
Cale,Section ut,upmraro Municipal Code.Chapter,9.1x.and the Heahh and Safe Roof
- _ .. ... ... ..... .....-....__ ._
HAZARDOUS MATERIALS DISCLOSURE
wn'Ne2�5
applicant or future Wilding«cupent sort nr handle haialloas material � Type Of R -
Cas eennedbyohe3Na)i..I.,"- .. sIt� 1dCii,l f.; y i. .y.` 'Is .i _,t,3 _,`.,.Y.Y ya ; :. "nt I,
ves ...,r�No,'., .I,.. _ _.All,roofs.shallbe.inspected prior to any.roofing material being instal led.. _. .
n
Willaeapplicmo or Boom wilding«Cupar use equipment or devices which If a roof is insialled without first obtaining an inspection;I agree to remove
nat hroardria,air Contaminants as defined by the Bay Arta Air Quality Management
ire '? .. all new materials for inspection. Applicant_understands and will comply with
rb, oy's. °No n all non-point source regulations.,,
i.
1 have read rhe hazardous materials requirements tinder Chapter 6 95 of the
California Health A,Safety Code,Sections 25505.25533 and 25534.1 understood that -
if the building docs not currently have a tenant,that it is my responsibility no notify the
accupon of rhe'requirements I�w.It t w met No m issuance of of.CeniEcme of
�� ( Signature of Applicant Date
- - Owns,ror.udwnzedagern '• I Dane- All roof coverings to be Class"B"or better
_ .. i OFFICE