01050121OFFICE
CITY OF CUPERTINO
CONTRACTOR INFORMATION:
]BUILDING DIVISION PERMIT
BUILDING ADURESS:
PERMIT NO.
1.1157 PALOS VERDES DR
CUPERTINO PLUMBING
OWNER'S NAME.
APPLICATION SUB DATE
PHONE
SANITARY NO. CON'1'ROLNO.
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ARCH)I ECT/ENGINEER:
BUILDIN'O 1117RMIT INFO
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BLDG ELECT 'LUMB .CIf
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LICENSHD CON'IRACfOR' S DECLARAHON
Job Description
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11 -hy'It did, I her-ed 1' t of '9( nnncncng
a,
with S t 70fXPj�+I /»^ i l h Bu yyhIC 1 mylactse
10c1`` q�
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i C4e,r a (9
COPPER REPIPE.
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Dal c I t s
tenni'% D[cl v m
undeamnJ m5 dols ,. nnWl be used do punt e rc rds
3 le
LiccnncA I'mlesniunul
OW NI aa.,lexemptHt in the Camomile's
I hereby infirm the I um .sump, from the Cs%inas is Ciccone Law fur me
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followa (Section 7113L5. Businessr, and Cale Any city
inguires
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❑
smicticounty
improve, demolish, y.t cern
witch q ecruconstruct.ape of J lit re
which a
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el
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itst
C icme,n
Prior I, ce. al rt4 e p applicant l M1 r period lite (Chapter
moth Ipurs a ,n p v fthe C t , r L I
Sq. Ft. Floor Area
Yalnil[IOn
ow Cor)
oniCalcl
hScchclionilandtheiv n,3nfthLBuY I din.
An P
or the bueix exempt ihemlmm and ,hl, breis fe the alleged pplicanoo Any
or kexe
l malty
of Scanlon )Idol 5lo any applicant fora Penni, wnjccF ,M1c applicant m o civil penalty
APN Number
Occupancy ML
Or nml ntnm ratan roe nanared mm�ats ($sa).
01, an owner of the propeny. or my employees with wages a% their sale compenwtion,
'- - -
Required Inspections
will do the work, and the an,tmre is not intended or offered for sale (Sec. 70J,
❑olness Lind Profe,im, Cn le: rim Cnmramr'n Licvns Law docs mol apply m an
weer of Pmpcity Who huilds a In,provcn ,hcrsnn, ;old who docs ouch xnrk ni n,cll
or through his own employed, provided that Bach improvements arc not intended or
202 — UNDERFLOOR PLUMBING
offered Ibr sale. If, however. ,be building Lir improvement is old within one year of
completion. the ownerhuildcr will have the hunden of proving that he did not build or
301 — ROUGH PLUMBING
improve fepnrpowofsale.).
502 — FINAL PLUMBING ENERGY
❑ L a. owns of me propeny, an eW.,i sly..... hts wi,b heem.m nummaory u,
it r,ofnsn,om. Cm 1,0 the Come:e
,minter 11heroae, (See.. mwq, Basin— ommm
507 — FINAL PLUMBING
License Law docs ma apply or an uwne of O,,)e,,y who Wilds or improve, thereon.
and who mmrucn for such projects with a eomrnemrL) recoved pursuant to me
Comrmmr s Liceme law.
❑ I no eacor d under Sec. . B & P C for mi, rtasun
Owner Doc
WORKER'S COM PENSAD(IN DECLARATION
I hereby attire under penalty of perjury one of the following declaIr ns:
❑ 1 have and will maintain a Certi6cmc of Consm to self-insure for Worker's
Cnmicmaion, as provided for by Section 3701 of the Labra Cute, for he
perorntencc of the work for which diiv permit is issued.
O 1 tool, and will ocair,ohi Worker's Co a,woo tin I Innmmmcu, as,,,,ud ed by Suolnn
3700 of Ile Labor Code, for the Perri ro.mme of ,hl, work lot which min permit is
'
issued. My Worker's Compewalion Inwratce came, .,,it Policy..veme, are
,icy No':
bCERT OOWORKI'_RS'
FICATI_%'` f^s
COMPENSATION INSURANCE
''i'his rcollan neeA not be enmplcm,I il'the Penni, is for Line hundred dollars
'
Ship) Or Icxs.)
1 cwHy that in the performance of the work fur which this Permit is issued. I
shall nut employ any Pewm in aw manner so as un become subject 14) the Worker'
Compensation Lawn of California. Date
A,encaot
NOI'ICE'g(1 APPLICANT: II, eller maklllg Itis Ccdilica, of Hla,00p,iou, you should
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be e.Le .omhO r ,he Worker's C... al minn Pruvisima or the labor Code, you must
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forthwith comply with such pmviaons or thin peri, dull he deenW revoked.
A
CONS'1'RUCUON LENDING AGENCY
I hereby .Bir then there is a enns,metion lending agency for the performance
of the work for which this hermit is owed (Se. 3097. Co, C.)
Q
Ll,ndar's Ni ii,
Lcndcr's Address
1 scarify that I have read this application and state that the above inownetwo is
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correct. 1 agree to comply with all city and county ordinances and %rare laws relating
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a building conxtroctorr:tad hereby authorize representatives Of this city to enter um
rye
Ibe above mentioned property for irvspeedon pur,vocs-
F.
(We) agree to save, indcnmi Is, and keep harmless the city of Cupcnino 11,11111
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liinlaics, judgmenrc, coax :seal cxpcmes which n,ay In any way ,moue Raioo .veld
City in O.low, .ncc of the 6o nlin, of,hi, Per 1.
APPLICANT UNDERS'EANUS AND WILL COMPLY WITH ALL NON-POINT
Issued bG2 Date
y'
SOURCE; REGULATIONS.
Re-roofs '
Si,emmof ApplicatNCuniracmr Data
HAZARDOUS MATERIALS DISCLOSURE
alehommnmaenhil
Will the upp- rcbugdhtglscugsooawoenrbmm
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Type of Roof
us dcaned by lite C."11111111Muni"I LI Cocle. Ch,mar 9.12. and ,he [Icahn and Safety
Code, Scainn 25532,/J't
D Ye. ON.
All roofs s all be inspected prior to any roofing material being installed.
Will the applicant or fumtic building Occupant use equipment or devices which
If a root' is installed without first obtaining an inspection. I agree to remove
cavi, hneamouu air comenoram, m defined bym. Bay Arca Ail Quality Manzgemem
all new materials for inspection. Applicant understands and will comply with
Dian<rr
O3'c'% 1:1 No
all non-point source regulations.
I have read be bzardnun mammal, requircnunb under Chapter 695 of he
California Hcal,h & Safety Cade, Sections 25505, 25533 and 2y534. 1 understand that
if the huilding docs not currently have a moan,, mm it is my responsihiliy a notify the
n s mich must be oaa Prior a louame ill a Ceniticate of
It ol',he esk,-
ccup:m Y.
Signature of Applicant Date
roof coverings to be Class "B" or better
Owneorhumor, �All
OFFICE