03010046 CITY OF CUPERTINO '•a '+. * •- t " ' - »y ,g
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ',I'.
BUILDING A DURESS: CUPERTINO PLUMBING PERMrr NO.
20392 SILVERADO AV 03010046
OWNER'S NAME: 10297 S DE ANZA BLV APPLICATION SUB DATE
TIMOTHY SULLIVAN 01/08/2003
DONE: (408) 253-0618 SANITARY NO. CONTROL N0,
ARCHITECfIENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
Poo LICENSED CONTRACT'OR'S DECLARATION Job Description
rx u F I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
�ZeY with Section 7010)of Division 3 of the Busincs.mnd Professions C sue,and my license is
z ;ntIL^I hC"mdcrfta 6 .n ` Z �O T WATER SERVICE/REPIPE/WATER ALr=O
zoq�
C y'Fy,p Datn — T} Ctintr. nr Y
�Oa� nom el I Its Rseh IIT}�Ci$ B C^ARdlaut TION
AN 3 0 2003
wLLOF'
.11]] OWNER- GB.DECLARATION
<� II herchy affirm Nat I em exempt from Nc Cnntme" 's License Law lin the BUILDING
fnlln4ing reax in.(Section]131.5,Business and Professions Cade:Any city or county
x$ which requires a permit In construct,alte,improve,demolish,or repair any structme
k;< prior to its isouance,also nyuires the applicant(nrsuch permit to file a signed statement
. that he ishcrowd pursuant in the provisions of the Contractors License Law(Chapter9 Sq. Ft.Floor Area $51940tion
y�0 (commencing with Section7kXh of Division 3 of the Business and Professions Code)or
y $
that he u exempt therefrom and the basis for Be alleged exemplion.Any violation of
Station 71131.5 by any applicant for a permit subjects the applicant to a civil Penally ofOccupancy Type
not morn Nen Eve hundred dollars($5110).
I,as owner of Be Property,or my employers with wager ss their sole compensation,
will do the work,and the..rare is not intended or offered for ask,(See.]1144,Busitmss Wp4yykI{{ �pf'�.(�pp�,.,
and Profession,Code:The Commune,License law does not apply man ewnlr,of 202 - UNDERF UKe lYl°1T311V G
prepeny who builds at improm Neuron,and who does such work himselfor though his
own employees,provided that such improvements sre not intended oroffered mrsale.N 301 — ROUGH PLUMBING
hswever.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of 3 02 — TUB & OR SHOWER
sale.). 502 - FINAL PLUMBING ENERGY
I,a owner of the property,am exclusively Connecting with licensed Connecticut to 506 - GAS TEST
construct the project(Sec.]1H4,Business and Professions Cade)The Contractors Li-
censeLawdoernotapplytoanownerofpropertywhoWildsorimprove&daemon,and, 507 — FINAL PLUMBING
who Contacts;for such projects with a conlractm(s)licensed pursuant to Nc Contractors
License Law.
ED I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRmr under Penalty of perjury one of the following declarations:
1 have and will maintain a Cenificae,ofConsenl to self-insure for WorkersCampen-
7301.1')
inn,as provide)for by Section 3700 of the IaMr Colic.for she performance of the
rk for which his permit is issue).
have and will maintain Worker's Compensation Iaumnce,ax required by Section
of Ne Iahor C de,fm a an.of the work for which Nis permit is Issuey Worke's Gem Inmm C cora, endP.1iCy...be,.
rrier: o Policy No.: 71901U/✓/7O
CERTIPICA' O'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if IM permit is forest,headreddollarf(SHXB
or less.)
I cenify,that in the Performance of the work for which this permit is issued,l shall not
employ any person in any manner sn as to become sunmi in the Workers'Compensation
Lawsof California.Dale
Applicant
NOTICE TO APPLICANT:11.after making this Cenilicale of Exemption,you should
Mcomc Subject to the Worker's Compensation provisions of the LMf Code,you mum
0 z forthwith comply with such provisions or this permit shmll he deemed invoked.
O CONSTRUCTION LENDING AGENCY
(ti .Ni I hereby splint that there is a construction lending agency fur the Performance of
the work Ino which this permit is issued(Sec.3097,Ci,C.)
Q Lender's Name
z Under's Address
U O 1 verify Out 1 have read this application and state but the above infntmmion is
IL F.r Centel.l agree to comply with all city and county ordinances and some laws relating to
�U building Construction.and hereby embodier representatives of this city to enter upon the
W Shave-mention)property for inspection proposes.
(Wt,)agree m save,indemnify and keep bees the City of Cupeninn against
HV) liabilitics.judg rte costs and ipcaa which
fn t9c y q y in any wayettrueagaim aaiJ City
U z in conscyucnc of he Bmmin ,this renis.
ra APPLICAN U DERSTA Ds A "WI C MPLY WITH ALL NON-POINT Issued by: Date
SOURCE i TI N.
Re-roofs
Signa A tc1,ATtAeDOrSMTE $DISCLOSURE Uare Type of Roof
Will the applicant or(mare mg txaupard in.or handle ha ardour material
as defined by the Cupeninn Muni 'pal Code,Chapter 9.13,and the Health and Safety
Code,Section 255320)? All roofs shall be inspected prior to an roofing material being installed.
El Yes No P P Y g g
Will the applicanw (Imre Muildingoecupant use cyvipmem or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haauNnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea, pNo
Have read the hyrardous mxmriels uiremnderClm,u,,fi95ofNCCaklir-
niallcalth&SnfmyCtxlc,5cetinns25¢ S �411, 1 undcrsmnJ lhatifthc huilJingdoes sol cnrrFndy hltt is rtInnGthe txta'.,of Nc
mean meniwhi,J mostM IpriorIi ficacof0.0 ey. Signature of Applicant Date
i / Dmc� All roof coverings to be Class "B"or better