02110076 CITY OF CUPERTINO rr.
BUILDING DIVISION PERMIT CONTR�ACTOR'INFORMATION: '..
BU20JNgpglRE,9:AN FERNANDO AV TRIPLE A PLUMBING PERMU-10211OO76
Are OWBEANhIIRICHARD H ET AL 1230 PEAR AVE #5 APPLIGATJO±r1Ljn2OO2
3oNE: (650) 964-4935 SANITARY NO. CONTROL NO,
ARCHITECDENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MUCH
0 0 0
Mist, LICENSED LICENSED CONTRACTOR DECLARATION
hereby at that I..licensed..ties provisionsof Chapter 9(cnmmencing WATER HEATER R�L�LLg9ftT
with Section and
efof Division 3of the Business and Professions CuJc,and my license is ���
in lull tome and effect. F per,
C��_ License Class Lic.M r N
Z Date Contractor
ARCUITEC'S DECLARATION
M1 understand my plans shall be used as public records NOV 27
xOSV
to Limmed Profcssiowl
firs OWNER-exemptRDE DECLARATION BUILDING $919
z e q I hereby affirm That 11. exempt from @c ContraelCo License Law for the
600 following reason.(Sector, Business and Pre.der ons h, ,, Any city or county
x$ which mqutrcsae,also orairel the alter,int lorsuh Permit
�re asiranystrunum
Fly priunniucensecc,alsant in ms the
sof lnr mchpenninnflcasigncdnatcmcm
t<
(commthat he encing
ccgwithSmtion70 BofDivision3oheComsiness ndProcenseaaw(Code) Y 3SegF6BIA6rAfdeQ Valuation
2 Bad
is ixemiNSersdOonIadd of Division ofthe
eged Business and Professions Code)or
— Nal he is exempt thcrefrnm and the basis for Nc alleged eumption.Any violation of
Section 9031.5 by any applicant for a Norio subjects the applicant to a civil Penally of
not mom than fn hundred dollars($500). 5O6p GAS TEST cwpancyType
❑ I,as owner of the propeny,or my employees with wages az their sale compensation,
will do the work,and Ne structure is not intended or offered for sale(See.7W.Business 50E? FiNAL Pb
and Professions Code:The Contractor's License Law does not apply to an owner of equlre nspeetions
property who builds.,improves thereon,and who d.easuch work himself or through his
own employees,provided Nal such improvements sone nor intended oroRered for We.If.
however,Ne building or improvement is cold within one year o(complction,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
le.)
.as—act Of Ne property,am exclusively constructing with licensed contractors m
nawct she project(Sec.704L Business and Rofeasions Code:)The Contrumr's Li.
cense Law does not apply to an owner of property who hade s or aspirins thereon,and,
who contracts for such projects with a contrmtogs)licensed pursuant m tbe Conlnmur's
4.imme Law.
❑lam credits or See ,B S,P C for this pension
Dula) I t 120
WORKER'S COMPENSATION DECLA
I hereby affirm under penalty of perjury one of be following declarations:
I have and will maintain a Centfcate of Commit to self-insudi for Wohei s Comped- '
7'17�'OO
ion.az provided for by Section 37M of the Labor Cale,for the performance of the
rk for which Nis permit is issued.
1 haus and will maintain Worker's Compensation Insurance,as required by Seetion
ofthe laorCode,for Ne performance of the work for which this permit is issued.
y Workers Compensation Insurance carrier and Policy number art:
rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not be completed if the Permit is for one hundred dollars(3100
of less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so az to become subject o the Workers'Compenaauion
laws of Califomta.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ceni0cam of Exemption,you should
become subject to the Worker's Compensation provisions of The labor Cale,you must
OO forthwith comply with such provisions or this permit shal lbe deemed revoked,
z CONSTRUCTION LENDING AGENCY
[+ � I hereby affirm dour But.isoconsuuetion lending agency forrhe perlimmnnccol
the work for which this permit is issued(Sec.31)9.Civ.C.)
WQ Lender's Name
w7 z Lender's Addmss
U O 1 modify that I have read this application and sure that the above information is
{rwP correct,l agree to comply with all city and county ordinances and stare laws relatingIn
C) U building construction,and hereby authorize representatives of Nis city m enter ufirm the
W shove-menrinned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,j.dgdimns.costs and expenses which may to any way acerae against mid City
(„) z in consequence of the granting of this permit. `
ti APPLICANT ON ERST N S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date (/ l/ G A
SOO CE REG TI
Re-roofs
Signarur f pptieanl/Contmcrof hate
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building Occupant suite or handle hamNous material
C-definesecd rbyetthz
e C.penim,Municipal Code,Cimide,1.12,and the health and Sufely
ceWe. ss3xan All roofs shall be inspected prior to an roofing material bei. installed.
❑Yes �N. P p y �' g
Will the applicant o,fnture building recupanl use egmissom or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit bamrdnue air es.
aminants as defined by[be Buy Area Air Quality Management all new materials for inspection.
D'stricu?
❑Yes
1 have read the mOodo.smaurn.ds rcquiremenu under Chapter 6 95of the Cadfnr-
an HcaLh S,SafctyC ale.Sec o x25505,25533 and2553L I understand Out ddte building
daub not cod ndy Cnanl,Wul it is my rcap.nslhillly In notll'y the a'cupanl nl the
mquircm wh' m mel poor In issuance Ola Cerilicam Ol Q'cupanC, Signature Of Applicant Date
rte- II,Z/o
norattbodudagenl Ilan All roof coverings to be Class "B" or better