01070062 CITY OF CUPERTINO
BUILDING.DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20212 RODRIGUES AV 01070062
OWNER'S NAME: APPLIC TION SUB DATE
TSU REX K AND TERESA C 07/16 /2001
PHONE: SANITARY NO. CONTROL NO.
O-Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
z00
O BLDG ELECT' PLUMB MECH
Hid —I L-1 t=J 1=1
H z LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
Fntw with Section 70)(@9f Divislod S ohne Bromesaaad Prafe:.:ion.Crop.and my 11 true REPIPE .
Y f J is in toll fort {f
e and ees
z z ss I.Rena Class Lic.M
e'O a O Dare Conuxtor
ski 3 a7�ARCHITER'S DECLARATcaoev�
C O 6 < JI�fn'Im101trypient Maill be used as puhlic rtcordt
�r
w cep O Licensed Professional
OWNER-BUILDER DECLARATION
n w-v I hereby aRrm that 1 am exempt Stem the Contractor's License Lew for the j>J 4
C>.< following Raton(Secdan 7031.5.burnous,and Prm'amCode:ole:Anr city or caadtr Y( $2000
'._C e which reyuire.a pct mit to cunwun.alter,im
uyivoc,demolish,or repair airy structure v
an pnorro its compete,alsorequeri theapplicant for such penin to fileasigcetlstaterman
hat he is licensed pursunnttothe previsions oftheContractor's License Law(Chaptert) i l Valuation
(commte
(commencing with Snon,7000)of Division 3 ofthf_'t
e Business and Professions Code) °a;1`36'913,,tCE4@9 a-v'%,_A'.,e, ✓
or[bathe is eximptthriclrom and the basis for the alleged exbriptloh.Any violation -
of Senior]031.5 by any upplicam for a permit mbjegs the applicant m a civil pcnalry
Lar nm mart than me hanarnt tlovam(s5oo1, 202APNUNBI$RFLOOR PL BING-. Occupancy Type
❑L as owner oithe property,or my employees with wages as then sole com,vowation. 301 ROUGH PLUMBINf
wiu'do he
and Pro dad the onfiode Th is not intended forsLi or ense Law
for does no apply roan 502 - FINAL PIR4B1Y1�QAspZU@RGY"
Basidia:and orle,oil h code:The Contractor's Livens:how tloa.t ale apply to an .
owd
<r of property Who build:or improves thereon.and who does such work himself 507 - FINAL PLUMBING '
or through his own hwetweecs, building
Nat such improvements are not intended or -.--
"';dfrired'for iale.'1[hbwev<q ihe builJine or improvement is,old within une'year bf - -' - ----�--- "� - --� _-' - ---- --- - � ,:
omplelion.Ne owner-builder will have the burden of proving that he did not build or
improve for pumosu of sale.).
p I,as owner of the property,am exclusively contrxting with licensed contmnors to ( t
t•
onsuuct the project(Sec.]044.Business and Professions Code:)The Contractor's h' c i
License Law tices not apply to as owner of prop<ny who builds or missives to Me '
and who conucen fmsuch.projccts.with a conuuctons7 licensed pursuant to Me
01..esca License Law.
❑lam:Imps uMet Sx` .B&.PC for this rtestm ��' .. s:!ti
_ Owner. Date' •'
WORKER'S COMPENSATION DECLARATION
I hereby aifmn under penalty of p,Ud,tine of the following decluratime,
❑ 1 have and will maintain'u'Cenifcaic of Consent to self-insure for Worker's
Compeveatinn, as provided far by Section 37W of die Iabur Calc for the
Performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as Upperm J by Section
.1 of the Labor Code,for the performance of the work for which this permit is
issued.My Workers Compensation InsuratRe carrier and Policy number are
C•ort.INf�+N. ST-, cae�'1W�J t'PulacvN :N LFL I ..ixI .CERFICATIONOFEOROMWOR E
..... .
,�COMPENSATION INSURANCE111 . • e' t i i f ._ ._ ,_-.__- __ ._.. _ r .-- _ ------
mitt section need not be completed if the Permit is for one hundred dollars •1 r l- "' -
i
i$100)or lets.)
I' n fy tb h P<rf m hh k f h6;1 Penn s- ❑ I -t rte
shall t mPloy y tyyuncyhhleNt th w krs
Co pc tet on L Cal ft-
APP( t bnuW
NOTIC[1O AV (CANT II,a her making the Certificate ofL<ntptitr.y .
become sObject ft-the workers Compensation provisions Of the Labor Cede,YOU must
Q O forthwith comply with such provision%ra thin permo
it shall he domed respired.
•''" ' ' •CONSTRUCTION LENDING AGENCY .,
F' 1 hereby allbur that there is a construction lending agency,hfr the performance •'- Y
of the.,k for wbicb thins permit is iaucd(See.309x.Civ.C.1
a'.f] Leader',Name _.. .. ..._ , . . _.. . . . . .. . ..- .. ._ ..
Lende.'.S AJilress
V I certify that I hread ih':application d state that the above f aeons
+'F. coned 1 agree to comply with all pio,ande tY ordinances andstate relating
Q.0 sob Id' gc n:loci acZL
y Lary ten p tet es ftht 'tyt ter upon
:the b e meter iy I armistice 'in
p rp _ -. =•v
f.L (W) grt J`T`mfydmf keep eithe C ty f Cupsn noagamv
1 J& J. Pimm h -Yin any Y gators smJ y i to t NT "DLI OMPLY WITH ALL PON POINT [Sslled b Date
RE( LY'
Slgrmuap'ofPfcantrContmemr Owe Re-roofs
HAZARDOUS MATEIUALS DISCLOSURE
Will the appbc to future holding occupant store or handle hvvdous rameA l .. Type Of.RQof .. -� •.- - - -
as defned by the Cnperi Municipal Cod Chapter 9,12,and the Health and Safety. - 1, ,
Cah, Section 25531(tiL �rr % ..• r f i'. t •�s i '' s s, ) :1 S ss-
❑Y<t All roofs shall be-inspected prior to any roofing.material being installed_, ,
Willthcapplicam or lulurc bililsling«cnpant ase egalpmcnt err eevicea.-men'. If a roof is instulk without first obtaining an inspection;I agree to remove
!emit haiardaus air contaminants as defined by the Bay Area Air Quality Management-
District? ,��� all new rials for inspection. Applicant understands and will comply with
Dyes ' �\ - ' all no poi t source regula s'. , ,
I have he haeumous materials Ryuircments under Chapter 1.95 of the
Culifom'a ahh& afety Cmle.Seniors 35505.25533 and 2533a.l undemand thin
if the huilJi gdoes tat curtently haven mnunt.thtnis roy responsibility to notify the :
ocduyant i them menti which merit be All to issuance of a Certificate of
Dccupume R - Ig to
of Applicant_ Date
7 6v
.• 'o a utharire agent , D„< All roof coverings to be Class "B•' or better`
OFFICE
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