00110143 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PIiRNII'T NO,
10*�P9 rTnNYnAl_F DR BUDGET PLUMBING 001. 101.143
OWNER'S NAME APPLICA'T'ION SUB DA'I 1i
. T 11./29/2000
• PIIONE SANI'T'ARY NO. CON IFord,NO.
(91 Mot ? 7
ZOZO ARCHIT'ER
CHENGINIR! � BUILDING PERMI r INFO
Pa_ BLDG ELECT PLUMB MECII
u� r_-I
a�w
Z LICENSEDCONTRACIOWS DECLARATION - Job Description
1 bcrehy affint Lha,1.,it licenses under,pravimour,of Chapter 9 Leoturencing
F:I-ca with Section 7OOBprr Di ,ars.infra,Businc,sanJ 1'mrnsinn,Ctdc.andmy.teen.
in full tutee and effect.
M6'ieenwCln„ Lie.# WATER HEATER REPLACEMENT
,°j 3 L. Dam Clinometer
ARCHI'HiCr'S DECLARATION
I ondennnd in,plan,shut he used as public mcoNs
S y
Our_ O Licensed Profcssinual
m LL 0WNER BUILDER DECLARATION
1 hioRmt that I am cliental front the Cnnlmmor's License Law for the
C < fulluwing rea,an.(Seel.....703 1 5,Basile..and Prof ..I..n,Cad¢Any city or eoumy
O which requires u..cant.to canama,alar,linpmve,dcnu IN,I air luty.euucluty
aim prior In its issuance.door requires the applicant lir such perminto file a sigtad aatemenl
Ill.heinccensedp...atmdepnces..int.nrbecnnnuenirsl.ieen,elawtchapter4 Sy. Ft. Floor Area Valuation
Ieot covin, .III Section Trial)of Div' n 3 anhe ILi,ines ival Pa.ressi..,Ceder
r that i,c,cmpl tleach mm nml one noel.rr the ul.egcd uaantpti.... Any 14 e
..f Sermon 7(1i 1.5 by any applicant fur a permit subjects the applicant tun civil penalty
of nm mum than live hundred unit.(55om. APN Number Occupancy Type
❑I,n of he prnpeny... ....nnpmyee w111,wngea a,thah.nle enal"ltaaana, Q
BuI Business
m�anwork, s%i the uile, I li C nar intended Li e e Law r ie snow(sea.Ida. __, _ ... _
Businns anJ Pmfc„ions Gde:"the Comriaor's Lmenw law ate.,now apply to an Required Inspections
r of pmpeny N'ho builds no improves an Inch and who J,es such wink intended
I,f
notedihhi.awn.,ni,,,.ttipin,dmnnnsuehinnical—nnarenmh..ccarad 502 — FINAL PLUMBING ENERGY
OEered in,tic.u.ter-h er,tire handing our hn burden
prat n,ala wmdn nue rend our
enmpmlion.me ownenmtlaer will have the barren our prm;ng that he ate not ham„r � 506 — GAS TEST '
itnpmve tar pnrpow our w.e.).
❑for,aner..fdtelropmm
.arny.an xcw,ten�yenelinglintJeanadeintracka,to 507 — FINAL PLUMBING /
nmn me pmjea(See.nay Ifnitte,,and Prnfcss.ons Cada:)The Crunictar..
License Ins due,nor apply m on rune,of pmpeny who builds er improves ahemm.
and who contract,tin such protect,with or contractors).icenwd ptrauanr to the /
01 anmpt
clmb Liccne See
❑lm cinunder
e
Se .IiK 1'C for this reunion
Owner Dom
-WIrRKER'S COMPDate LION DITLARA'IION v
1 herchy orlon under penalty at perjury one of(lie following dedamrina, .
O I awe and will alaialull a Ccnificatu of Csrnr,aol to wlf-insure aur Worker',
Gtmpetnaliun, it, pneund linby Seaian 37001 of the Lahnr Code, for On,
perfommnce of the work four which this permit is issued.
❑1 have and xil.ntalnmin Worker',Compensation Inwmnce,as required by Sce inn
3701 11 1he Lahnr Cuda liar the pedintr n¢u if the work For which thh panni.i,
sued.Aly Workar's Compensation Insurance currier and Policy number arc:
Garricc Policy Nn,:
CEN I iIFCA11ON OF EXEMPTION FROM WORKERS'
COMPENSAHON INSURANCE
OThiv acarian need sat be completed if the permit is far one hundred dollen _
($100)ur IoM)
1 cenify that in the Ia'nnnnancr of she work Int which this feutil is issued,1
,hail sat employ any Pennor in any manner w,m it,to c subject m the Workers'
Cnmpensulion laws ol'Cuatontia.Dote
Affliction
NOFICH TO APPLICANT:If.alio nankin,chis Ccnilicale of Escmption.Ina should
Femmeu
subject the Narver'%Compensation pmrisio is of the Lahr Cudi.von moa
Q 0 foals all comply wish such provisions or Thi,print 11 shall be treated reclined.
u O":f CONS T HUM[ON I.17NIIING AGENCY
aI herchy alTnn that in a coroametian lending iifnuhe perfnrmana,
fol ur ahs work fur which this Pennr i,issued(Sec.3097.Ci,C.)
ALeri Santa,
.= z L<nder's Address
U O 1 certify that I have man this application and state that the those mfnmtatien is
,unmet.I agree to comply wish all coy and county unlinanen's and smB laws nelming
QVmhadiingconartaan,]heneby unionize reptewnnaivv,of this city lim
r enrultnn
thisn.
e aMwe-nv:ntiuncJ pun,so lir inspeclion pur,asv.s.
r}Fi y (We)agree unions,iadcnniry and keep hmnlms the City of Cut no against
fO Iiabilin”.judgln al"marc and e,lxnw,which may in any way accost,again said
V Z
City In cnn,cquence of tire gnneing 11 Nps permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY so 114 ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
SigsummofAppllnualCntdtural Uam Re-roofs
IIAZARDOUS MAI'HRIALS DISCLOSURE
Ni Nc applicant or future building teeupaat.awe or handle lwanRtu,malerid Type of Roof
as defined by the Cape nine Municipal Gde.Chapter 9.12,anJ the Health and Safety
Ctrl,.Section 25532...1" -
❑Ye, El Na All rool•s shall be inspected prior to any roofing material being installed.
Will the apNroamormture lateeingoeeapart ttseeyuiparantnrdOiccs which If a roof Is installed without first obtaining an inspection, 1 agree to remove
earn ba,ttrdnn,:dr emmnlnmaln,as defined by the nay Area Air Quality Managerial
Di,n'ierr all new materials for inspection. Applicant understands and will comply with
O ye, 0 N all non-point source regulations..
I have read the Imrardous nonerial,requiren¢ms tinder Chapter 695 of the
CatlrnW Health at Safety Ciotti,Need 255115,255,13 it 1255]4.I undcntanl dim
it the building docs not currently aura a utnam,akar it in my re,kn,bilily funnily Ott,
accu sate of the roquircmenls which nun be mm prior to issuance of a Certificate of
Occupancy' Signature of Applicant Date
Oxnerm aathnH,cd agent Daae All roof coverings to be Class "B"or better
OFFICE