01100162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: .
BUILDING ADDRESS:. PERMIT NO.
20654' ,SCOFIELD DR '" " BUDGET PLUMBING 01100162
OWNER'S NAME: ` ' APPLICgTION SUB DATE
COULTER.'CLYbE B JR AND' EDNA C 28695 ROANOKE ST 10/31/2001
PHONE: - (510) 264-1113 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
O BLDG ELECT PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION
ZI Z I hereby mem that I am licensed under f Chapter 9(commenting lob Descr tion
'„” pro"P"°'° P e WATER HEATER REPLACEMENT
se :rich Seaiorenndafect. bn3of the Business entl Professions Code.end my
L e full farce and effect.
p w Ua. License Class Lice p
i3c. Dae ' SDECAContractoF'�O /�
ARCHITECT'S DECLARATION ,V�'�G ED
.u O 4 1 undemand my plans>hall be usc0 as public rcmrds
I iC a o Licensed Professional MAY q 2
' e 0! 2 OWNER BUILDER DECLARATION 8 200
1 hereby affirm Out I am exempt from the Contractor's Liven.law for the
d?¢ followin&mason,(Smtion'/031.5.Business and Professions GMe:Any<iry nr county - $500
d zz o which requires a permit to construct.clue,,improve,demolish.or repair any structure
ou ._prim mite luuarme.also mquires the applicant for such permit to file a signed statement- - -_ --- - - ,- --- - - - - - - -----_ ---- -- -_--
that beisli¢nsedpunmmhitheposisionsofthe ContmmorsLicense Law(Chapter 9i r- i PValuation
(rammcrr gwahSectienl700(l)ofDivision 3af,hcBusiness ad Professions CadCON N .�9'1Ft4( C_ _Agr ; ..C; s ;
m that he it c.empt therefrom and the basis for the alleged etemptioa.Any violation ..
-of not mo than iv any hundred
am fm a pemrirsvbjeas the aPplisam to a civil penalty.
of not marc than five M1anarcd aauara($saB). 502�PN SAIL PLUMBIN ENERGYOccupancy Type
❑I,es owner°f the property,or my employees with wasp,as thcir sole compcmaaan. S06 - GAS TEST
-win.pomrwark-arta'the'awcmrei.'nnolntended,, fcrcdf sale'(Sea-'7(W4f 507 - FINAL P]&Tdd�41H'�ddlaspec[ions
c Business and'Prefeamns Code:The Contractor's License raw does not apply.to an I 1 I)\,',
owner of progeny Who builds or improves thereon.and who does such work himself 1 i
or through his own employees.provided that such improvements rte not intended or '
-offeiW forsale.If.hosessr.die buildingorimpmvenrcm ii solJ wialin one year of- --'�- - - ----- -- -------"__..-_. _._..-.. _-._ _
completion,the owncobuilder will have the burden of proving that he did act mild or - - •`` •. L' 1.1{S:.
improve for purpose of sale.). 1 ...
. .. contng with hearted
arte
❑Las owner,ofthe propeny.am Buexclusivelyinsand contracting witCodc:).Ticonmamomto „. ,^r-^•e� -
mnswm the t(Sec.7044,owners property
Professions Chea The improves
tai,eon,
. .. o. projcc ' , t�.'�1 I' ?'R .,,sll
.
"- License Law dues not apply to an owner th propcnyorm Wilds scimproves thercdo.
:: .and who convects.for.Law,such,projects wim.a.conl..... )IicensW Pursuant m-toe. .. ._viii._.__._... .._ _..__.__..._..__...
C mm�ors porde Lew.. ,
: - _ ❑tem emmpwnder Sec:" n .B&PCfar mis season !,111 �"•s:s ^-'1f L,.i
_ Owr ' Oate I'•
WORKER'S COMPENSATION DECLARATION
' .i hereby ammo under pewhy°f perjury one of the following dedamtions:
❑ I have and will maintain a Cenificam of Consent or self-insure for w'erkca s
Compensation, as provided for-by Section 3700 of she Labor Code, for the
- - 'perforrnarrce of the work fm which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Scction -
3700 of she Lahor Code,for the performance of the work'for'which this Permit is
issued.MyWorker's Compensation Insurance career and Policy by __-....._..........._..� .............«viii..
Caermrs l C ��l V i PV11ey No'. r
!CERTIFICATION OF EXEMPTION FROM.WORKERS,
' "" COMPENSATIONINSURANCE" s.`..- 't•' r -
` fThis'zcclion need nm he c°mplacd if the permit is far one hundred dollars
•1001 I s) .i. . � � .. r -. .r. _ .........._.._ _
.- -viii..•..,,_...viii.-_. ..«__.-.._..... ... ___. .� _.... ...-..
I enifyy'ht'in th prf of work hch th pe t a"d'1 ✓ <I,P `
ihail not c nploy any Pe any manor to become subject to the Workers
Compo at o Lews of Cel Tome Dem'
Applicant •. .: viii ... -_. .. . -_.--. .__ .._ _._..____. ....__ ._._. _ _ _--- _-_.
NOTICE TO APPLICANT If,after making this Certificate of Ept you should I _ - - .I ` --_ It �.�... s
Became subject to the Workies Compensation provislonme of the labor Code,ymi must '
O forthwith comply with such provisions or this penniuhat]be deemed revoked. '
V�Jr a+CONSTRUCTION f ENDING AGFNCY 1 -1
a ' to Ih by iRm thauh is n stma on lending gamy( N'pcif.'-"lince r ryI
Wer of the work for which thi t i,- d(Stc..3097 C' C.)
Lender's Name .:o...
Di•z 'tder's Address s-
V 1 comfy that 1 have read this application and state that the.W formation is
corn t 1.,mam comply.,mat with .]Lely ad c umy & nd..t 1 lung --- - .
Q [) to bu Id g co trvnbn d hi thourepresentatives ofthis city t t upon
y he atu e n ent oned Pr pent'f pectin p rya
W V
(W)dg ee t sa s mticmmfy ad kelp hmml ss the.C ty of a pen at said - - -
�y.W
liabilities.judgments costs d xpe s which y, any way cc a against send
V, City c nscquena of th/eJgmnt g f'hit peAnlL
SOURCE
APPLICANT
UNATIONSDSL�ND WILL COMPLYW9TH ALL tiON'POIVI't` Issued by: Date
sgaatyreorAPgedaavcmttracti,r,:. ... : .. . :�,pme�,.:.;;' --Re-roofs
HAZARDOUSMATERIALS DISCLOSURE 7
ik to ppmant ,sere a,lanic whore m handl Kamm tm,al Type of Roof -• --_.__.._
as def cd by m C pert o Municipal Cod Chapter 9 13 d theHealth d Safety
,af,(•(. s• " - - ---,,i
Cl+d s t ss53s( y -I �r 11, + - (' tT^.! " �'r - 4 �. !�'�'°.1: �1•+i; 'c. „_. o
'°Vas ❑N f"'^-' , - ..__All roofs shall be inspected,prior_to.any_roofing material being installed..._ _ _
-Will*aapplies.,or I, am building«eup.at use cquipment.m devices which' If a roof is installed without first obtaining an inspectidlig l'agree'to remove
emit hasssdous air contaminants as deGilW by the Bay'Arca'Air Quality Management ,
Nomel?x a olvh - _ all new materials for inspection._Applicant understands and will comply with
a l
:.+ ; all non-point source regulations;,
4� 1 ha e read"the hamrd .fmamn.I qtr rcrnents.lmde Chapter&95Vlibc
California Health&Salary Code,Sculme,25505,25533 and 25534.1 understand that
ng
not
of .pari,ofthe;esuircme s 'in ten ant.that prior myrepernuance off tohficat,the
.
ocdupant o!Nc iequircmenss wNchtmuit barna prim to issuance of a Cenifieeo.d. -
!.. 0ccapancy.. :...
,.. ' . ..... . :.:. .. . "'.'_ , .. Signature of Applicant..- _ •__ - - -_Date
Ovm odam age r Dam . All roof coverings to be Class "B"or better
OFFICE_