01020016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10183 RIEDEL PL CUPERTINO PLUMBINC 01020016
OWNER'S NAME. APPLICATION SUB DATE
HARRINGTON ROBERT D AND THERES 10297 S DE ANZA BLV 02/05/2001
'� ruoNL
(408)283-0618 SANITARY No. coNlxol.No.
pLie z ARCHI"rTC)IENOINEER: BUILDING PERMIT INTO
z w 6 RLDG ELECTad
PLUMN MECH
a>ad
S y Z I,ICI!NSED CONTRACTOR'S DECLARAI ION .lob Description
I h 1 y all m I I l . J came,pIIw1,i.asofCI1a1111 9leo 1 nun ng
0" ow 'IhSection 70guolDi Ir lith andI (..was Cndc. ray lI lueenw
a I�Illll I ' I Tg COPPER REPIPE 8• WATER SERVICE
mit a I ccs Cl lis b _
Kia. SD I .r c'r
Aa,1Ila'II;euse ULCublic ON
g 1 undeeaunJ rely(tuns shall be used as public record. +p.,I�w
m z p p l,iten.al Pramuianul '
DLL OWNERdf UILDI3R ULCI.ARA'OON
uKi=w 1 hereby amnn that I son cxcanpt from the Contmclnr's Liecnw Lew fiu the
C following ninon.ISceJml 7031 5.❑usiness and Prof ..tons Code:Any city sur manly _
ce 1-O which mynuc>a permit In cnn.wrarl.ghee improve,demoliah,ret repair any stmnan,
0,c.3'° prior yan
r its Lwce,alto requires the applicant lot such pemaitin file a.smmmem
signed n
that he is licensed pursuant to the provisions of Line Contractor,i-wernse Uw elcipter 9 Sy. Ft. Floor Area Valuation
(commencing with See.ian 700(q of Division 3 of the Business and Profession.Code) $Jr, ��
or that lie is eaempl therefrom and the ha.is for the alleged emmptlon.Any violation
of Section 7031 S by any applicant for a permit wbjecu the applicant to a vat it penally
Of not more than live hundred dollars(S500). APN Number Occupancy Type
D I.as ow net of the pmpeny.or my employees with wages as their sole coanpcusanoo. 31621057. 00
will do he work,Dail the structure Is nal Intended or olmred for sale(Site.714x,
B.,in,s and Profos.ions Code:The Contractor's License Law docs not apply to an Required Inspections
(miter ofpropeny Who lwJds or nnproveithereon.and who docs%ush work himself 202 — UNDERFLOOR PLUMBING
othrough his own employee..ponat that such improvements am not intended or
onamd for sale.If.how<ver.the building or imponsmem s sold within ant,year of 301 — ROUGH PLUMBING
nnimpletion,the owner-builder will nine the burden of proving Inco he did n n hoild nr
+proveotpumnscarsalc.l. 502 — FINAL PLUMBING ENERGY
D 1,.o owner oche unparty,um cWlusivelr contracting with framed contractors to 507 — FINAL PLUMBING
Iout III I'j tlS 7I44 B .. I['nor.. C l ) [l L na"ou"
'll not apply lip- p ty 11111 build .Jha,aru,
Ind xl I' I' In, a111 +pu' if, t rnainat () lict,owd sur,caut it,due
clunarla,,I Law
D I;nn cauupi Linder Sec. .B A,I'C lin hi..reason \/
Owner
WUHKIiR'S COMPENSATION DECLARATION
I hereby alBnn under penalty of perjury one critic ILllawing declanourn.:
❑ 1 have and will maintain a Certificate of Consent to self-none for Porker:
Compensation, as provided for by Section 3700 of be labor Code, for the
petfarlamce of the work for which this pcmtit is issued.
❑1 hose and will maintain Workds Compensation Insurance,as required by Section
3700 or the Labor Code,for the performance of the work for which this permit i.
issued.fMM W/nr_kle 1Ca p/y inion I�n./y,� �e cam(L end Policy nuniarare:
Carrier! r�WIIAL 110M kY:1�No.: NJ02 0
L✓rsP CIFU IICNIJON 01;EXEMPTION FROM WORKERS'
COMPENSAIION INSURANCE
TThis Swinton Iced 11111 aro cwn+p[,led it he p,nint Is for ane hundred dollars
IS 100)sur lcaa.)
I certify I In the I+rrlol mance oI the work for which this permll in issual.I
shall Intl employ:Dry I+cnorl in any actinic,so ax m Imv LSa,l m the W..kern'
Colmpanmliun Laws sur Callbania.D:ee
Appbcwu
III IO AVPI.ICAN r H.Bola making This Crnnicum of Eaenlplinn,you xI Id
hceomestuco n,@e Worker's Conlpe. no
..inn auln,innsot the I,ar Cwdc,you 11m.I
O C Iimhwilh comply wilh such pn+visions Lir,his pencil sfall he Dermal revoked.
Z
H ` CONS'IRUM[ON LENIAO AGENCY
as I hereby nlfiml that there is a amAraction lending agency for rhe performance
of the work for xhich this penial is issued(Sec.30197,Co,C.)
6. A I.endch Name
= z Lender's Addre,
U 1 cenity that I have read this application and sine that the above information is
F.. coned.I unce a+comtply with all city and county ordinances and state laws miming
O {) to building construction.and hereby amhwriec mprc.cnmtives of city to enter urym
the Bowe-manioned propcny for inspection puU+owc
I„1 ILL (WO agree it)save.indemnify and keep harmless the City of Cupertino against
V1 liabilities,judgmenn,nils and c.pc :s which may in any way accrue against said
U z Cily in conxyucnm o the gmm mi.=rmiL Z S ro
A " IND "AND, v )WILL COMPLY WITH ALL NONPUINr
S if a .I Issued by: Date
sigmuurc+ p1,na11Vconwnot Re-roofs
I IA%ARDOUS MATERIALS DISCL(1$URI1
Will mrnrpur;I I or bllela building wPWpaor..ore ommrdle ha.unlous nmnedal Type of Roof
a defined by the Cmsn Mn Mnnidpul Code.Chapter 9.12,and the Ica101 and Safety
Code,Scuti11112.i"2(a1:'
DYas ' D No All roofs shall be inspected prior to any roof-Ing material being installed.
wlunleepprrmnnrrmorebuilding occupuola.ecgaipineit ,,dcviccswnib If a roof is installed without first obtaining an inspection, 1 agree to remove
mit hanndnu.Dir eoultnlln:n+d u.s defined by the Stay Area Air pn:dlly Mlnwpnnan,
,ni.smicrr all new materials for inspection. Applicant understands and will comply with
D Yes DNo all non-point source regulations.
1 hmr .it the hamrdous anaedi 1.reyaimumals under Chupmr 6n.1 of the
Calillsmis Ileahh N Sally Code.Sections 25505.25533 and 25534.1 undcnland that
if Jing Acequig,�tiv ...roam.thin it is my msryrmi ifa Cluify thecapam f rhe yuircmus M tact prior m issuance of a Cmihntc of
top" Signature of Applicant Date
�- I b
—��� All roof coverings to be Class`Brr or better
owaer sur sumorimal ng � nate
OFFICE