02110032 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON,TRACTOR+INFORMATION
BuIPA52,9)JAAINBOW DR JEFFERS ROBERT E AND ANNA MaRMII'N92110032
GWtY.-IPMERS ROBERT E AND ANNA M APPLICA_TV%r1U5Tr2002
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IFZONE: SANITARY NO. CON 1701.NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°OZ LICENSED CONTRACTOR'S DECLARAI'[ON
won Job Description
p I hereby affirm that 1 am l bead under provisions of Chapter 9 O'ommemens GAS LINE
P
i wi fh Scnlnn ad effco.vision 9 nld+c Business and Pmfassions Ctdc,unJ my liconm is FINALE®
��= in full a Gla and dfcm.
License Class Contractor OZ—° Dale Cl+nlmelnr DEC^=Y1-� ARCA]I ECT'S DECLARATION LI 1 1 2002
C d a I understood my plans shall W used as public records
aoau
u�3 H Licensed Pn+lbxsiunol
i dsm OWNER-BUILDERn the he CiATION
1 hcrehBUILD�1�
y affirm Thal I aexempt froom Comor
nct 's License law for the
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no lo1hus ng reason.(Sucunn]8315.Business anJ Pmfexsinns Cade.Any city or county
22! which requires a pxmit In construct,alter,improve,demolish,nr repair any structure
prior it,it issuance,aim requires the applicant for such permit to file a signed statement
�£Si6 that he is licensed pursuant to the provimons of the Contractor's License Law(Chapter 9 3WBt0F@d07A&0 Valuation
yFa (commencing with Section Ilig)of DivisLm 3 of the Business and Proc ions Code)or
i 3 3 that he u exempt therefrom and the basis for Nxe
e alleged exemption.Any violation of
Section 71131.5 by any applicant for a permit subjects the applicant to•civil penalty of PIV N Occupancy Type
not are than five hundred dollars S5an. 202 - UNDERFLOOR P UMBING
I -owner of the properly,or my employees with wages as their sole compensation.
illdo the work,and the structure is act intended or offered for sale(Sec.]M4,Business OUfif
ar B{Tg
ifS
and Professions Code:The Contractor's License Law does not apply to an owner of 3 02 - TUB & q J "ct1Ons
propcny who Guilds or impro.ss IW rcon,and who does such work himelrar through his
ownemplay.e.prov+ded that such impmvemenuare nmimmmded mriffemd tarsale.B. 502 — FINAL PLUMBING ENERGY
however,the building or improvement issold within ane year ofemmplclion,the owner. 506 — GAS TEST
builder will have the burden of proving that he dm not Wad or improve for pur nme of
sae.). 507 - FINAL PLUMBING
❑1,as swties of the pn+peny,am exclusively contracting with licensed conraxors m
conswcl the Pmjcct(Sec.7014.Business and Professions Code:)The Conlrmemir s Li-
u law does not apply to an owner of property who Wilds or improves Ramon.and
who contracts for such ptnlec s with a confirclor(s)licensed pursuant to the ConBaetors
License Law.
1 am esemp}rniler c. .B&P C for is and
tend Dam I O
WORKER'S C//UMP SP r DECLA TI
Iherchy affirm under perfa4 of per tory oneof lW following declarations:
1 hale and will maintain a Cenihcare of Continuo selLimum for Worker's Compen-
sation,as provided for by Section 3700 of the IaWr Code,for the performance m tbe
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as mquired by Section
3700 of the lahor Code,for the performance of the work for which this permit is Peace.
My Worker's Compensation Ism once carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EX EM(TION FROM WORKERS'
COMPENSA'T'ION INSURANCE
(This section need not W completed if 1W permit is foronc hundred dollars D100)
IcssJ
I certify that in the pwrh+rm a of the work for which this permit is issued.l shall net
employy any ry:raon in dr to astn suhject to the Workers Co pe aljon
tawadf Calif D
Applrcan
NOTIV TOAPPLICANT:If,site kin is CeniEcnc of Eacmp on, W should
becon subject to the Worker's Co.,mauo0....:.inns of Ic Labra Cr ,you must
o z fon if comply with such provisions or this Permit shall W dcemcd mvoked.
Z O CONSTRUCTION LENDING AGENCY
PV) Ihereby affirm that there is a construction lending agency for the performance of
a i the.,it for which this permit is issued(See 3091,Civ.C.)
inLender'sName /Jt�
=0. z ttWve Lender's Address
U O 1 nify that I have read this application and stow that the ainformation it
correct.0 F-t boingt.I agruensu to comply with all city and county ordinances of am stare laws relating e
Qv ado.-mentioned
pm rty hereby authonprposes.representatives of this city to enter upon the
aM+vc(We). m 1.muse for Inspection fu add keep
ha
(We)agree m save,indemnify add keep harmless the City of Cupertino against
liabi lines.judgments,cosfund expenses which may in any way accred ngainm said Ci ly
U Z in conequencc of the granting of this permit G
+-^ APPLICANT UNDERSTANDS Aj4D WILL COMPLY WITH A L NO -piNT Issued by: Date
SOUR' EG LAT Or.y
C/ Re-roofs
st ate mAppheenOcon' oar Type of Roof
IIAZA Sts TE t1AL5 DISCLOSURE
tZVill the applicant or future building occupanlmom or handle hal aterial
as defined by the Cuienino Municipal Cndc.Chapter 9.12,and the Health and Safety
code.S❑rettbon fing material being installed.
s
If a roof is installed without first obtaining an inspection,I agree to remove
Will(he tipph,urfi o to"building Occupant use equipment or device,which
emit notorious air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distrix!
❑Ycx o
I have mud the W,ardnus materials requirements under Chapter 6.95 of rise Calif n.
thin l lcahh&solely Code,tuons25N ,25and 155}1.l uakrmand thaif the ildi
docs no,emmialy have a w ant,Na is m533 slamsibiloy doily the twcu¢ trem o F
requirements whi um mcipd it u C caof e / Signature of Applicant Date
owme oraumoisdagent D c �� All roof coverings to be Class "B"or better