00060077CITY OF CUPERTINO
BUILDING DIVISION I PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRE,S9
OWNER'S NAME..
LICENSED CONTRACTOR'S DCCLARNTION
1 hereby affirm that I am licensed under provi.iom of Chapter 9 (commencing
with Section 700(n of Division 5 ofthe Buvinesx and Prom,,Ions Code. and on, license
, in 1.11 h,me and effect.
License Cluc. IJ .#
Date Conlmt9or
ARCHITECI'S DECLARA]'ION
1 underoand my plans shall M lived us Net reconlx
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby anion that 1 um exempt from the Contractor's License Law for Nt
bellowing muses. l scedon Il31.5, insures, and P f ..tons Code: Any cover mwuy
Mitch requires a permit I, n,n...mt, allcn in.pmvc, demulivh, or repair any slmcmrc
prior,. itsi,o el oI the np, icam lo. mh Nonlit to l ilaasigned cimntn,
'flat he is Ilemoed pi to the provish,nv of the Contrunor's License Law (chapter 9
(commencing with Section 7(M) of Division 9 of the Business and Profev%kaw Code)
or dem he is cumpl increment and he mI for the alleged weo nption. Any viulalion
of Section 7031.5 by any applicant for u permit mhjects the applicantm a civil Penalty
of not more than five hundred dollen ($500).
❑ I. ussennr of the prnpcny, or illy poployec with wages n flair sole compon alion,
w111 do Ihewurk, and dm-vlmclurc'is not imcnded or offered for sale (Sec. 7(94,
liu,inms and Profcxnin I, Cn IT: The CunIne,lor', Lieerve Law dues nal apply m an
nef of property Who build. or improve, thereon, and who does omh work hi—elf
or through Iris awn engdmyoe,, provided that such impnnemenn are not intended or
offered for sale. 1f, how'ev'er, the huilding or impm ,own, is old within one year of
completion, the ownerbuflder will have the burden of proving that he did not build or
improve for per, is. of sill.),
❑ 1. as motor A The nol era , am e¢Imively eon nmol, with licensed contractors In
mvtruct the preject (See 7044, Rosi,^.. and Prol'vv esvimCasuD "Ilse Contractor',Licerm Law dress not omly to an owner of property who heikk or impmvcs thereon,
and who cnnln¢ls for such forces will, a commeor-O) licensed pmsunnl to the
Contractor's License Law.
❑ 1 am exempt umlcr Sec. . Il & 1' C for this reason
Owner One
W'ORKP;R'S COMPENSATION DECLARATION
1 Tetchy utl'linn ander lwnnity of Ire Jury one of o Illluwing declamlin I,:
1 sl have and will mainmin S Certilicam of Consent to sell-inmrc for Worker's
nnpensminn, us provided fur by Section 370D of Ne Labor, Case, for the
performance of the work for which this penult is issued.
0 have and will maintain Worker's ComPen,ation Insurance, as required by Section
3700 of the Lbor Code, for the pvrtornmove of the work for which this permit is
Ironed. My Worker's Cnmpcnnmiu i Iuwrunte......
on qyI her
CorrioL Villi ..
Policy No j ` �Vo
CHRI'IFICAI'ION OF EXIIMPI'ION , KOM WORKIiRS'
COMPhNSAI [ON INSURANCE
(This section need not be completed if the permit is fortune hundred dollars
(51110) or less.)
I cttd(y (hal iu the Nerforinun c of Inc work fm welch this perail is iv cal, 1
,nw1 ton employ any ntr,mn in tory �op�aner tut, tux To nae. `it�e�dne wturor,
Cumpcnxmitun l awn nl ',)ilia i Dom_" 7
Appli am
NOTICE T(l Al' ANT.1.aper making Cenificmemf Gsemption.,Ntl,muld
become subject , the Worker'. Copensation provisions of lite Labor Case, you must
O 0 nm
forthwith comply with such pmvisimn% or this permit shall he deemed revoked.
'Z—' V CONSTRUCT ION I.17NDING AGENCY
aI machy infirm that there iso enngmetion lending agency for the perforin ce
oI IT, work I'm which too permit i, Itmed (Svc. 9097, Cm C)'
0.Q Lcndcr's Nunes
= Z Lender's Address
U 0 1 cenify that 1 have read this application and sate that the above information is
Lzs t.. comet. I agree to comply with all city and county ondinnnces and .m¢ laws reining
Q U to building constmdion, and hereby authorise representatives of this city to enter upon
the ahove.men i I property for Insrycfina purposes
} y (sem agree To save. indemnity and Ire, hannlcv, the Clly of Colorlim, against
V] Il:mllifev, indsmrnt... cos.. and evir-n— which m any way nem agaln.a said
U % Ch - the 6mming of thin ItuY in c
City g pe CO
APPLICANT UNDERSTAND NO COMPLY WITH ALL NON -POINT
SOURCE REGULA'N9lM�
Signature of Applica—nU ,fore_(r2Dam
.AMA[TRIALS DIS WIIIInt applicant or Came building etut store handle
Tao mate'twl
ode 1by the CulnnmelMunid1lCode. Cheaper .12, and he Health md Sally
CodeSrSbex
255)200:'
❑ Yes
W 1 the upplicunt or future building occupant use equipment or devices which
mit hmaTdi air commninanls as ddmed by the Bay Ams Air Quality Management
9lrlety
41❑Yen
Ihave read the to colour mumnalu reyuiremenlx mn.ler Chapmr 6,19
5 of the
Cal ifumla ]Icahn k Sn1'ay Code, Section; 25505. 25533 and 25514. 1 m,Aeru;urd Inut
if the huilding docs nest currently bout a mnumnh:n 11 is my responsibility tom,Ilty the
,eclipses of the reyuiremr�i which i1ust� ton prior to issuance of a Certificate of
PP.RMIT Nos.
APPLICATION SUR DNI H.
SANIFARY NO. CONTROL NO.
11 11' INFO
BLDG EI.I!CI' PLUMB
R VE— IJ t;—;,, 7_
Job Description
(510)293-9901
WATER HEATER
Required Inspections
3661.1.054.00
502 — FINAL PLUMBING ENERGY
506 — GAS TEST
507 — FINAL PLUMBING
Issued by: _
Re -roofs
Type 7f Roof
Date
8789
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant
Date
All roof coverings to be Class `Br' or better