00070038 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
B II I I.D INC,ADDRFSS: FIdVvII'INo.
OWNER'S N. APPLICATION SUB LAI 1:
Y
`755 SOUIREHILL CT CUPERTINO PLUMBING 00070038
Iona:: ONI ROL NO,
DAN POLCYN 10297 S DE ANZA BLV SANITARY N07 /10/2000
CceZ ARCHITECI7F.NGINEER: PIU IL DING PERMIT INFO
tat-00 BLDG E,1.1-'M 1%L j It MliclI
(408)283-0618
u I�1 f.1 I'_'I I:J
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- LICENSED CONeTRACTOR'S OEC n,ofc[ON
a,
0 5 v. 1 i i 70 affirnr mat L am of ander prnv,unn%oP Code.and
ndmyB low, Job Description
FNC•y
with Hecrinn7gNpnf Uivision3 of the Bu>inens and pro(esinm Cole.and myliceme
< is in hull fnccand c t
o Lian.c,Cj Lie.
cr,rC.K WO
Connor
soy ARCHmiTSn[cnRA O'' REPIPE/WATER HEATER
�] 1 unden,and n,y plans shall Is, mrd
used uv public ens
6
a',, Licensed professional
OWNER-BUILDER DECLARATION
I hereby affirm thin I.,it c.empt Bnm the Counacnr',Licence Law lin he
L�4 following rw..on,O,,00n 7031.5,Busmen,and Pmft,,ionc Code:Any city ,,county
S xt ct whim requires a pcnna to construct.alter.impinvu,denu,l isb,or aep:ur any onletum
naw prior In its iamance.nBo requires the applicant for such permit file a signed%ancront
that heis licensed patnuannalneprnv,,,ntool inComincuu, Law(Chluc,9 Sq. Ft. Floor Area Valuation
(vommenci ag wllh Scainn 7010)of Division 3 of the Business and Profession C%de)
or that he is exempt theist min and the basis for con nll,Od exemption.Any violation
of Section 70315 by any applicant for a)smut subjects the applicant to a civil penalty
of nor more than me hundred dollars(s50(n. A PN Number Occupancy Type
❑1.is owner of the property.nr Or,ca plu,evs with wage,to then sole em.sciou ion. $5000
will do the work,wd the%acorn is not intended or offered for%ale(See.7021.
Bovines,and prohea.ion,code:The Contmcmr'e Uc e.,e Law doe,nm apply it,no Required Inspections
ov,octofirropcoy who bdlds or itepnwes thereon.and whit does such work himself 36223020. 00
or through hl.own valideo.pnwidvd tem such Impn,vmncnt,are not IntendN nr
offered for sale.If,la)" ver,the building or improvement is sold within one year of
completion,the overcubuilder will have the burden of proving than he did nm build or
mpm%ea„peH...vof%de.). 202 — UNDERFLOOR PLUMBING
❑Lan ownerofthe prapcoy,onivelooivelycontracting with licensed Conote T%in 301. — ROUGH PLUMBING
construct the t(Sec.711,14,imonew and Podesvion.Code:)The Cbmmetur'n
" si 502 — FINAL PLUMBING ENERGY
Lleee,e L:aw doe,a,n apply m an owner of property woo m,Ba,o,improves memo%.
and who contract,far.such project.with a contranar(O Iicen.eJ pursuant to Tac — t
Cl,1..to igeorde Sec 507 FINAL PLUMBING
❑l amoxe,mm�ndersee .BffiPClor This nu„
0.her Dam
WORKHR'S COMPENSATION DECLARATION
I hcrvhy of inn under lwrally of perjury one of the following duclarabonv / 00
<j
I have and will maintain a Certificate of Cmovm m sch-imure for Worker i 31 /
'ont
pensation. n provided for by sector 3700 n1' the Labor Carle. for the
,donor a Of the work for which this permit is issued. L'\
❑I baro:old will moor in Worker'%Cmnpcnsa,ion Instance,as terminal by Section 1/ O
JJ1,,701�p1 if the Iabsu(�C�ore.for the pc�,ffn-rnwnee of he wad for which this permit is ,
7x 5 oris C'tKvrNk`/M 1` [ and Policy numao ice:
mYatk v107 3 4
C c [�[1�QNLlis—folic No.: __Q
CER'1lp1CAT1ON OF F.XEMIMON FRO>1 W ORKIHtS'
CONWENSN'ION INSURANCE
t his colon rmc,l not becomplocl if,hc permit is for one hundred dollars
od 00)or lea,.)
I terrify that in the performance or the work for which this retail is iswed.I
shall nor validly arty per airy neone,so aum
s ,hccne nobject to the Wnrkcrd
Compensation Laws of Calili um..Data
Applicaet
NOTICE TO APPLICANT:If,after making this Cenillcam of Exemptionyou.should
C 0mbecoe nubject m he Wndcr'n Cnngs oa,iou provisions ,I the Leon Code,you molt
forthwith comply with such provi%ime,or this promil h.11 be deemed revoked.
Z rn CONSTRUCTION LENDING AGENCY
I hereby mim"ram There Is a cnnstmci.,i lendingagency for the pefom,ance .
Of the wmk for which,hi,pe.,it is issued(Sec.3W7.Co.C.)
6. Q Isnder'n Name
5 Z Lender',AJJrtm
V O l certify that l have lead this application and%late that ae above intonation is
I. c,o,, I agree b.corn Ply with all elry rand county ordinance,and state law.relating -
OTJ u,building construction,and hereby autboure repcluddives or thi,oly tocner upon
the abo n-ovar 4 ed prnpcny ler i nspcaion....we,.
F 0.
(We)agree jostle.indemnify and keep hannic,%tac City,d Cupsnino agmina
p) dirbilities,jadgmenre,viols and evicand which miry in any way u,cmv aadtot Laid ,
U z City' %c active j th a ting of this permit. '
AI ,1CAlIT D-fayyy 1S AND WILL COMPLY Wrol ALL NON-POINT Issued by: Date
SO Res -7
si nrnnphcamla%m, e,r umc Re-roofs
I IAZARI )11. MATERIALS DISCLOSURE
Nill,he applicant or ilding occupant%tort ter handle harallous rna¢nial Type of Roof
as defined by the Cupcnina Munlelpal Code,Caapwr 9.12,and the Health and Safety
Code. O`Ye.355320x0° E3 No
All roofs shall be inspected prior to any roofing material being installed.
Will hemppficomnrmrarebnldingne,inaeta,,11.1pmeet ade,ov, hieh If a roof is installed without first obtaining an inspection, I agree to remove
'mit hamolnus air comamini mx a,define l by,he Bay Arca Air Quality Management
,i.trlen all new materials for inspection. Applicant understands and will comply with
❑Yes 0N all non-point source regulations.
1 have read the ham,dou%materials mgairements under Chapter 6.95 or the
Califio nla I Icahn 5 Safety C,dc,SaBnnn 25515,25533 told 25534.1 n idershmd tan,
if the building docs not currently have a It that i,is my m%Vm%ihdity to nobly the
ace pant nl tht myulmrnuns which rnua he met poor m iswmncu of u Ccnilicrne of
Ocvcp...y' Signature of Applicant Date
Owner ,,amhnno"d.,cut Dare All roof coverings to be Class "B” or better