03010045 CITY OF CUPF.RIPINO
BUILDING DIVISION PERMIT r CONTRACTOR INFORMATION
BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO.
11129 SUTHERLAND AV 03010045
OWNER'S NAME: 10297 S DE ANZA BLV APPLICATION SUB DATE
TANI STEVEN N AND PATRICIA D O 01/08/2003
ZONE: 400 253-0618 SANITARY NO. CONTROL NO.
ARCHI7ECl'IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�U-
LICENSED lasta COM'RACnOrpare,CLARATION Job Description
U I ion 0 affirm thnt 1 am fuse Bd under provisions nr Chapter Y(commencing P
with Section and
efe Division Sof the Business and RnsressinneC Jc and mylic��is
in ton tone and cff Z REPIPE/WATER HEATER/WATER SERVICE
20�� Licence Lic.M
p2nF. Dam - Cllnlr or pT1 FINALE®
�oWV lander n aRC 5llbeo JasplruccsM9 r 'V
3LL Limen J MAR 1 2 2003
^'O m OWNER-BUIL . CLARATION
fa� F I hereby affirm that I am exempt f nm 'Cnnuamnr's Liccnsc Law for tM
i S p 0 rnllowing..,in.(Section 7031.5,Business and Pndeash s Code:Any city or county
$ which mquires a proton to consumer.alter,improve,demolish,or repair any structureBUILDING
Fye^
poor it)its issuance,man requires be applicant far such permit o rile a signeJnalemenl
Yap that he is licensed pursuant to the pmvisious or NC Conlrulnrk License Law(Chaprer 9 Sq. Ft. Floor Area $SU00tlon
F (commencing with Smdan7000)of Division 3 of the Busircss and Professions Cartel or
So $ that he is exempt dominant and the baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy e
net more than five hundred della.($50r). P Y '7 P
❑baso,,„(the property,or my employes with wagesss Oak tole compensation.
will do de work,and the surname u nal intended or offered frr sale(Sce.7040,Business 202 —
bNDE 'M
and Professions Cade:The Comrshemes Licenae Law dors not apply to an owner of 3 01 — ROUGH 3s typ') CC Ions
IMO
PrnPcny who hmlma orbarrows thereon.and who does such work himselfor through his
own employees,provided that swh improvements am not intended ornlRred for We.If, 502 — FINAL PLUMBING ENERGY
however,Oc building or improvement is sold within am year of completion,the owner
builder will haw the burden or proving that he did not build or improve for pulsus of 507 - FINAL PLUMBING
aalc.).
❑1,as owner of Ne property,am exclusively contracting with Emmet combustion to
construct Be project(Sec.7044,Business and Protessiom Coder)The Contractors Li.
cense law does not apply ns an owner of property who builds at improves themon,and
who comment for such projects with a cnmracmrpl licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec. .B AS P C fm this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby arm under penalty of perjury ane of the following declaratiom:
1 have and will maintain a Certificem of Consent to Welt-inmrt Canadian.
Worker's
satinn,u provided for by Section 3703 of the labor Code,for the performance of the
work for which his permit is issued.
❑I have and wilt ainpm Worker,Compensation Insurance,ss required by Section
7)We'NeW , performanm or the work for which this Permit is issued. ,
My Worker' fixator Ins o.artier and Policy number a re:
Gamer. t Policy No.: 13 l���7000
CERTIFICAT EXEMPTION FROM WORKERS' r7GO
COMP17NSATION INSURANCE
(This senora need not M completed if the Permit is for Inc hundred dollars(S EMI)
fir Icss.)
I ernify Nat in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner an as m Meome subject to the Workers'Compensation
Laws of Celifirmia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificae,of Exemption,you should
hecomc subject to the Worker's Compensation provisions of the Labor Code,you must
0 ,z forthwith comply with such provisions or Permit shall M dammed revoked.
O CONSTRUCTION LENDING AGENCY
I hereby affirm Out there is a conswainn lending agency for Ne performance in
p: ti the work I which Nis permit is issued(Sce.300.Civ.C.)
D.1 Q Lenders Name
l,'
z Lender's Address
V Q 1 centry Our I have read this application and sue that the shove information is
II. P correct.lagree to Comply with all city and county ordinances and sate laws relating to
O U building construction,and hereby ambOriM representatives or this city to enter upon the
W shove-mentioned progeny for inspection purpecacs.
FL
(We)agrey osave,indcmnily an .ICccp h Inss @c City of CuPcninn against
rA liahilitiu'ud cnu.moxa and bxpcn which ay in any way aCrne against said City
V z in consrs�e eu(tM ggPPnn'ting of Permit.
APPLIC 'UND RSTAND ND W PLY WITH ALL NON-POINT Issued by: Date
SG - 03
Re-roofs
naw. ApP icon onRDO _
Data
HAZARDOU IALSDISCLOSURE Type of Roof
' Willy ca Cupemnr rMuni building occupanthpsroreor handle I leardousmatedul
ss dclined by Ore Cupeninn Municipal Cash,Chapter 9.12,and the Ilcallh and Safety
Code.Section 25532(.)1 All roofs shall he inspected prior to an roofing material beim installed.
� ❑Tea Nm P P Y g 8
i Will the applicant fir future building oecupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hLiliux air momamiarms M derined by the Bay Arca Air Quality Management all new materials for inspection.
Dinrim7
❑Yes No
P have head the hr rdnusmnLLrials requiremen n@rChapch695ofBaCalihu-
niallcalthSSafesyc ;Sav 25505,255 imp X.IundcricandtMtiftMhuiWing
does nm cuj�s(dy ve a tens ,that it is res Oility w notify the occupant of the
nquimm w m rdipdnnr SusanrRrea nrQmmPamy. Signature of Applicant Date
�D/` d
thnri sJ entAll roof coverings to be Class"B” or better
ncr or uagDam