00110132 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
ti!WILDING ADDRESS; PERMIT NO.
22660 SILVER OAK LA BUDGET PLUMBING 001. 101.32
OWNER'S NAME: APPLICATION SUB DAIH
S __ RAN i.—ACEY 28695 ROANOKE ST 3.1./29/2000
I-�PHONE: SANITARY NO. COM'ROL NO.
/ OO ARCIfUEm lHINGINFER: IfUI LDING PERMIT INFO
m BLDG EI.EM PLUMB MECH
NyE r_I 1-1 CI I=1
a
L57= Lrat bar
underSOECLARN9nN' Job DCSCflpt101t
u, I hereby aErm Aha I a 3 0 In lit
ander provisions.II.of Chapter 9(commencing
license
�_tw with actioneanef Did nn9ufthu Businw.and Prcdcesiuna Code.unJ nryrlicenm
feu films and erten.
g10 Date class Lie.» WATEP, NEATER REPLACEMENT
3 S d h Dale Contractor
ARCM ll be UI!Public e...it
ION
°5 i nndednnJ my Pl:utn.hall bet:n pante rcennls
C a' Licmned Profc..aimtw ,
aiod
OWNER-BUIL.,IanDER DECLARATION
w o y 1 hereby oleo on I tun camps from the Cessions C s :Any c law fnu the
t_ +' fallowing renna.vrinit t 703 LA t.all r 5 and ub.de professions Code:Any can m county
7 prin t myuirn a Ixr...to ai cs the applicant
i for esu h wrineh,ur repair any tatement
d $ , noslicened alio reqsint thw.,itrsol for mchpvmdn Li,cm,le a signedstatement
m.t rip iauan>lid par.n.mrn�mc pnw�.wn.of me Cont�.�nt:x uan.e wwtcllapteru Sy. Ft. Floor Area Valuation
I cnntnteneing with Scums 70(NB of I a, 3 of the Il usinca,laid Prorcvsion,Cold
radial he is exempt therenom and the had,fm the alleged nestptiov.Any violu'um rn
of Section 7031,5 by any applicatn tar t pemlu snbjcctx the apPlinmt u,a civil ncn'nhy
of not more than foe hundred dollar.l55flo). APN Number Occupancy Type.
El 1,as owner of the prumi or my employees with wages as their sole compemalon, :/ 4 Or
will do the work,and the structure ix nm intended or ol'I'cred for sale(Set.7tDLL. '
:W mc and Professions Code:The Comranor.Limoe Law does not apply u,an Required Inspections
„,wrier of pmpeny Who build%or ruipooes thereon.and who d;w.%well work bimwlt
r through his owaemployces.puts ideAtha%achimprovements amnot intended or 502 — FINAL PLUMBING ENERGY
offered for sale.If,however,the building or improvement is sold within one year of
untplction,the owncr-bulldar wlll buvc nne burden of proving mat he did not build or 506 — GAS TEST .
mpmoe fm nurpow,of soli).
❑I,a5 owner of the proem,. 4.emlo,ivela contracting..i win,licensedcontractorsCee man's
507 — FINAL PLUMBING
mown the ue%no tape. In an lmssrowner o and ery who h Codon The Cmnm neon.
and who
Law don not apply In an owner with
a county who bunds%c Impnmea memos,
and who contracts f r well projects with a amwcmnn)limnwsl punuuty it,the
Cham Lxc%Licen
1 se
Law.
❑1 vin expmq under See. .B&I'C for Wie reason
Owner Dare
WORKER S CUM 1'ENSAnON UECLAItAI'10N
lty
nic
I e ad will n under timin.Cerafixrjuof Coa,fnce,, cf-in..c for or
O as
I stn—vnJ will maintain a Cecil irate sl Coocnt n,eclf-inxure for Nfarkche
Criturnsoneo he provided for by action 3781 of 0e LUMn Ede, for the ^�
Pedismwnne of me salt for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as requirN by Section
37W of the labor Crane.sur me performance of the work for which this nernan is
stied My Workers Cnmpensatiun Insurance carrier and policy handier arc: -
Canier: Pol icy Nn:
CERTIFICATION OF EUiMFI[ON FROM WORKERS'
COSI PEN SNI ION INSURANCE
rl'his action neW not be eotnplu,ol It the per nu is On,one handled dollar.
(SIIXB or less)
I certify that in the pert uta once of the work for which this Permit is issued,1
shall nm employ any Person in any farmer to as to become subject to the Workers'
CO i'enwinmia
tion Laws ofcr , .Dueri
Applicant
NOI'ICH TO AI'PI.ICAMO 11,after staking this Certificate of Exemption.You should
beconrc sobject m the Worker's Coml+•mation no isions of the labor Cole,you must
Q O forthwith vvtnply with such pmvivion,or Wis permit.hull be dcancd masked
6 V
CON SSRUC'I[ON LEND ING AG ENCY
} 1 M1umby affirm that there is.canummdon lending agency far me pcffmnnnrm
of the work for Is hick this pen id i.-seed sin.3097.Cl,C.)
Q Lender',Name
.7 Z Lender'.Address
U I certify that I have read this application and state that rix above information is
I.. �r a rmct.I.gree to entad,.,It,all city and county mdmtmcn earl ata,laws relating
[) to building coaamction,and herehy enhance repmwnmWcs of this citym enter upon
} y the above mentioned nropeny for inymetion purpows.
t„ttit (We)agree to snoe,indemnify and keep harmlevs the City of Cupertino again,,
7V1 liabilities,judgments,cols and c,NiuN%which may in any way dean,against said
Z_ City in consequence of tire granting of this Ixmnit.
s)UBCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Signature of Applicant/Contractor - Otte Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the.,It...I in mince hording n,„tenant eon:o,mnmlle ha,; I r.owmdtd Type of Root•-
n&dined by in Cupeninn Municipal Calc.Chapmr 9.12,and the Health and Safety
Cole,Swiun 25532(1
❑Ye, ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or satire buo,rtngoceapaot;,,c cgnhinomtor device,which If it roof is installed without first obtaining an inspection, I agree to remove
,tont humNou,air mmamin:mu a,defined M1y the Bay Area Air Quality Management
Donn"? all new materials for inspection. Applicant understands and will comply with
El)t,' 0N'o all non-point source regulations.
1 h:n'c read me h:vnnlonx toaeritd,mquant rid,under Chapter 6.95 of the
California Health&Safety Cole.Section%25505.25533 and 25534.I arthr mad that
II Ow building dors nn,mmmtly Lou a mut 1.thin it'mshym nuibility to not ify the
occupant of the requirement%which must be amt prior to iauancc of a Cerofflum of
Occupancy.
Signature of Applicmtt Dale
Owner ar aothericd agent Dap All roof coverings to be Class "B" or better
OFFICE