00090065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BIG ILINING ADDRESS: - PERMIT NO.
1
'ownea'SNSME:10461 nrrl.lcnnoNs n ;
0065
hlNE: PETERSON :ANITARYN0. cvarfle9-
z
0]. AW:111'1'1bridiNGINEER.. i=!113,6-0b 18 HUR.DIN .PERMID IN[1)
0
HLUG I?I,ICCf PLUMB >11!Cfl
W
mI,ICpNSEII CON')RACfORS DECLARATION
oco I herch'a il- In,l am teemed ander pnwi....lea m Chapter g(corporealJob Description
InEu with Strtion 9tHH0of Division3ul'be❑minc,sanJ VroIE,siuns Cvoi,,I du,lice....
<y„ i,inlulllarceanJg /- /� p
g z eo< Littn,e Class_ Lic.M fOL .1
Date_ �e"p nom stn - IN
RE—PIPE/WATERMRIN/CI RL SYSTEM
ARCNITECr'S D[CLARA'1'
I undnlnemd Iny plane 1111L11 be uncd lie public reread,
y ti p Licensed 11rnfesJonA "
OWNER-BUILDER DECLARATION
=N 1 hereby affirm that 1 am co mpt from the Contractor'.License Law for the
s-2 y folk-inn ree,ou.(Section 9031.5.Hneinea and Profession,Ctdo,Any city oreuumy ,
€O wthd 1, roller 'u t 1, p J 1t,, r I ,aamtre
ca pr art f I' 1 IIe'PPr fl 'IP tin Ila b d.,mama
�— tbattle is wemeslpursmmntmthe passions of me(. mown—Licue.La (Charter9 Sq. Ft. Floor Area Valuation
ammpenciag with Scene.7000)o'Division 3 of rhe Husme,u and Pon essinas Ctdel
to,that he in exempt therefrom and the basis far the alleged esanplion,Any violation
lel Section 7031.5 by Iny nppl;cunt lar it permit auhleet the applicant to a civil for
or mminore man live htmdleddollars N500). APN Number Occupant
01.on owner of the pri or my enfployce,with wages as their cafe compensation.
rill Jo the xork,and the venture is not intended or offered for sale(See 9044. ;
RusinnP
s and mfension,Cto Are Commi License Law does not apply u, 3570705
an Zdegl.9Vcd Inspections
owner of ppcny Who built,lir nnpruvcn thcrum.:mJ who rices such work hinndf
,or 11 m
1hlm.gh hl,-a o cmpl..yee,:'pri,idel that each Ingmvvalues me nm imcndcal lir
offered It,sale.If,however.line budding o,I„Iporinran,i,-Id willim one year,.i 202 — UNDERFLOOR PLUMBING
icompletion.the owner.lwimer will have the burden ofproving that he did not holder
ni for part or secs.). 30] — ROUGH PLUMBING
❑1,as..wnm lir the pmpery ant e.cla,i1v rcumr¢tirg with fiacrl,ed a,nnnt..'n'01 502 — FINAL PLUMBING ENERGY
andnfnmt the pmjc,,(See.9W4,Bud,wss and Profn.lors CnJo,l'rhe Contraam's
Mol comiforsuc aaatect%vd,a Gear who nmldamonpravaatnto the _ _ 5t�7 — FINAL PLUMBING and who a.da far such project with o mm, no l licenced prove, r the -( 50
Cammctnrx License Law.
xe
01 am empt under Sec .H k P C for this mare
(loner E
W(IRKUR'S C(lMl'DateNS ON DIiCLARAg]ON
I hctchY af(imt under pcnahy of pe,jury ane of the hslbwing tkd:uationc � '4F/
hslvu;,,it will nnuinntin n CcniGcwc of Gnfamm ¢,nclf-Innurc for Worker',
pI'n
❑Impen,n,ion, sec voided far by Section 49110 of the Labor Code for Inc
,no mnunce of the work for which this permit is issued
❑1 have and will maintain Worker',Compensation Informal an required by Section"Ion of the Ln Ma Ctdc.for Ihe portortranm of the work far which his permit is
;must.My Worker', odea Insurwn:e cunli'er and policy
�Ill Err am
Carrier: \7Lf �tn{�Policy Niv:V1J�/ U 3S-7
Q r
CUR111:1 ATION Oh P_XLMl ZION I:ROM WORKHRS'
COMPENSATION INSURANCE
f rhN action ,,,d nut be cnmplemd it"Ina prnnit Is for line hurdled dollar,
(16101)lir less.)
I certify that in the pcdappame of the work for which this permit i,I...col.I
shall not employ any person in any manner so as m become objet to the worker,
Conlpensmlon laws lel California.Date
Apple;a
NOI'ter;TO APPLICANT:It,ane making this Cenill al l?acmptlon,yon.remold
be,le subject u,the Wookcr's Comperson pot visinas lir the IaMn Cor ton mans
Q 0 forthwith comply with such p.Wi n,lir rind,permit shall be dermad revoked.
.�.ICONS TRUCTION LENDING AGENCY
I brachy ad itIIn mot thele is a con,uomtoo lemons agency for per tan amc
al the work for which thio permit i,issued!Sec.3107,Co.C.1
6. Q Lrnder's Name _
= z Under',Adol
U I certify III,,,Ihove mad thio application and stmt,thin file nlawc information is
em'.ct.I agree ,,comply ,It,all dry and cru n,'ordinances and orale laws relmn,
Q U mhaddingmmd'o1.and hereby onthnriaercc,wwumfi,n,nf lid,city to enter upm
} (� the above-mewcntioned pmpery IDI in"clum purynses.
!Wel agree to save.indemnify unJ kap harmless the City of Cupertino against
N liabilities.judgment,.enafs and capemm which mar in any e'ay accrue agaiaa said
U City is eunsegnenau of the grain 111g lel'mi,pant...
APPLICANT UNDERSTANDS AN D W I LL COMPLY WITH ALL NONXOI N'1' lasted by:• �� Date
SOURCE REGULATIONS.
Signature of AppheardContmcter Dam Re-roofs
IIAZSRDOUS MATERIALS DISCLOSURE
Will mcapnt,e:Int lir ream ntdmhfgt,ccu, t omre'or hntme lfa.nnman,o'llial Type ofRoof
n ddincd by the Cupcnlnn Munlelpal Ctde.Chapmr 9.12,and file 1EaEh and Safety
Cole.Section 255320C
All roots shall be inspected prior to any rooting material being installed.
Will the applicant or future building occupant use equipment or deices which If a roof is installed without first obtaining an inspection, I agree to remove
nil hvmdons air conuanlm,me as dctlred by the Hny Area Air Quality Maneycnncol
all new materials for inspection. Applicant understands and will comply with
❑Ye, No, all non-point source regulations.0, )w
Ihave read the hvardons ma¢rak requimmrnu under Chapter 6.95 of the
Cali fmniu Health le Safety C'oto,Sections 25505,255!3..it 25534.1 undcamn I tum
Iftire bllluon glnot....really ha"amutt.thou if ie mmpunw
y . ,ihility ..otfy l he
ecul of olc µ�s whld sf h i,xnana of a Cenili T
`l"n1Signature of Applicant Date
Owre,o,amm......dugmt �ac All roof coverings to be Class "B" or better