01070046 CITY OF CUPERTINO
BUILDING DIVISION, . ' , pER1VIIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO.'
1518. PRIMROSE WY CUPERTINO 'PLUMBING, ,01070046•
„�' _ _
P I TAMS$ RAND'NORMA J — 10297_-S; DE ANZA' BLV 07 12 2001
TIC. .
PHONE: -(408) 283-0618 SANITARY NO, CONTROL NO.
�
C ac 2 ARCHITECr/ENGINEER: BUILDING PERMIT - O
02
sC�. BLDG ELECT PLUh MECH
a e. 1=1 r=1 I J I=.1
LICENSED CONTRACTOR'S DECLARATION
z N I herebyaffirm that I am licensed ander fcha ter 9 momm<udn Job Description
a provision,a P 8 WATER MAIN.
F_,t_w with Section DivisionJoi the tlusiness nnJ Profusions Cute,and my license
6 m g is in full fomc an Re '
e LittrtseCWU
C_lass Lic.p (Ay, U
3 a.rn Dam ARCHITECTS DECLARNUI N
F=O g 1 understand on,plain shall be used as public.,oldors
�N
dpO Licensed Professional
>I,-,h OWNER-BUILDER DECLARATION
I hereby ullirm that I am exempt from the Comracror's Liccnu Law liar the
F x' fon g_ (see"
ID]15 i . ss and v?deaons Cour Any my or count' , t $1000 '
E t D
which q pe t t i t h r rmprovc demolish,or rtpa r any stmnurc --
ac 3'� po t t a al q di Pu cant ser such pemmn to ale a,thea statement
but
'"t
it nseJp uxmmd pro .ionsoftheConapon"causelrw(CTapmr9 3 6}O�lcp Ta Valuation
(eo are is Sect n]UW/of Divis on3ofthm Busimr.d Prpfesnons Code) )�fa _ Iq- a�l ei iQ
oraha he is exempi thcrcfrorm"unJ the basis
for the
allegrd exemption.Any'in
-of"
f"e Iirn 7W..by any applicant for a permit Wb"ch,the upPlicant n u civil D ralty
lof not mom than five hundred Collars lS500). 202, �MQD19RFLOOR PL BING" Occupancy Type
... 01.as owner olthe property,or my employees with wages as their solecompensaaon. 301 ROUGH PLUMBING ��,r
'. '• -will'16'thb work:'and'the structure is not Intended lir offered for safe(Sec.7044," _.502.-r.... FINAL. Plti n�Nrm� C"J
Basinax and ProfessionsCode:The Contractor's License Low art`s not apply to.an. .-_-. .. WPGV WIS t>i�GY...•_..... ... ........ _....... .._..... . .
own fpr his
bold mpo.sthrco na Dad«, ape intended
nndedor r 5017, -.- FINAL PLUMBING
of 8h E ply provided that h pt. t t t
�, ff amd d f I It h thebuilding P t Id within - Year or
of. . .-.
completion.the bold will have the burden f provingtht Wdid hotbuild or
improve fier P To. fi l )
con tust.he phovep,(See.TU Business and Professions Coda:) C thwaio❑I f@ propy t i 1J contractor,'x
License Law does not
apply to an owner of property who Wilds or impthereon.
and.who pormach,for.such projects with a contructons)licensed pursuant to the
,
n..
Cot n L'c n e W
° S 1' .R&f C for .,on
I am exempt under c
Owner t Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under lty or perjury penaone of the following declarations:
❑ 1 have and will maintain a C,:m icute of Consent to sd ar,un,for Worker's
Compensation, as,provided for by Section 3]W of the Labor Code. for the -
_ 'performance of the work for which this permit is issued.,
°I have and will maArm Worker's Cnmpsoxib rn Itnumnm as mqulred by Section
37W of he Labor Code for 0e pinfirrantruse of he work for which tti s pent t is
suep, y Work s Comm on Insurance carrier d Pikicy numberart:
�Cn "I•,C.r ns ., Ptil'<Y No (/K\LtSi��1kiii 1�.
CERTIFlCATION of EKEMPf10 FN ROM WORKERS C '
"COMPENSATION INSURANCE,.. ,� .. ._ _ __ _. ...__.—___ ____�.... __ ..- .. ._,_I ...__ _._ _.
t s' (This aimr*pced nut be enn,plcmJ if the permit is for ane hundred dollar
(Sl W)m lessd t
1nfy,tnatheperformancegL the work for which Peiissued.1 }.
' shall rh c'PI y anYP_ Y,an h c
�:t onbled m thecit Workers .. �. •." ._ ' . .r. ' -• .,--.... ....�
Comp`s ition Laws of Cal forms.Date in o rm
I
Applicant '...'
NOTICE TO APPLICANT:bac
Ir;after nmking this Ccrdfcnm of Exemption,you should
z .Zn ehwiih cmnd,with such provision each,pmrisinnsll W dLuber revoked.you nun '
fo } s or this pcnnit shall he deemed revoked. I
CONSTRUCTION LENDING AGENCY
a"71 hereby urlirm[hut(here is n cmwmoion lending ayca f to the performance
of the work for which this permit is issued(Sec.3097,Civ.C.)
Lender',Name _.. . .. .. - _ ..... . .. ..__. ..
�' Cl Lender's'Address r
. U;o, ,
U 1 certify that 1 have road this apphommo and nam that the above information is
h'f^ prompt.I agree to comply with all city and count)'aNin:mces and shoe laws relating
U to bulIdt ng construction,and hereby vuthbrim representatives of this city to enter upon
r� the above.m<mloned Ptoltchy for mspe,o purp,,-,.
l\t'e).,me toaavc,indemnify and keep harmlesslhe City or Cupertino against
V] liabilities,judgments.costs and expenses which may in any way ucme against said
] V Ci sequ NDER rhe D. Nofthispermit. J'�
PLICA, NDERS AND. NO WILL COMPLY WITH ALL'NON-P INT —a V
Q c RR IL . 'I c• _ Z� f Issued by: Dale
signature ofnppn anJCmrrnpto: Da¢'.- Re-roofs .
t HA]A OIS I
pATERIALS DISCLpSURC
Willtheplicl .flim meg occupant note or handle hvaN a,matemal Type of Roof,. - ,. _ . . _. . ...
as def cd by 0 C t n
pe o Uun c pal Cale.Chapter 9.12. J the acids and Safety _ t . ,
Code Section 255321 i ,: ' I°«' .. : .
°Ye ' " : .,,�- ° ' . .....Allroofs.shall be inspected.prior_to.any roofing material being installed. .,.
Will the applicant or future buildingpecupaot use equipment or devices which If a roof is installed without first obtaining an inspection;.) agreeto remove
emit hazardous air contaminants as refined by the Bay Arca Air Quality Management
Dotdce. ., all new materials for,inspection.,Applicant understands,and will comply with .
ore, °No" all non-point source regulations., _
I have read the hmxtrdnus mnicrial,requirements under Chapter 6.95 of the - -
CaliforniaHealth&Safety Code.Sections 25505,25533 and 255311 understand that
.if the building does not currently base a tenant.that it is my responsibility to notify the
olsid
e ucmenh,xh must be met prior m issuance of a Cer ilicam of
SignatureofApplicant Date.agent Date All roof coverings to be Class "B"or better
— '"' OFFICE