01120054 ci of cuPE , .
BU CONTRACTOR INFORMATION:
nuu.m:gc DIVISION, PERMIT,
l D ItIC. - PERMIT NO.
7�&f� `FPUGGLE PLACE ' CUPERTINO 'PLUMBING
W 01120054
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:_ .... owB'T'L"£Mf'KINCAID ,., ., . 10297"S'-'DE"ANZA-BliV`_._.._ A 1'
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HONE: (408) 253-0618 SANITARY NO. CONTROL NO.
z Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
ed ed O BLDG ELECT PLUMB MECH
8'z
5 v Z LICENSED CONTRACTOR'S DECLARATION Z SC Pt .
IM1creby affirm thin lam licensed under provisions of Chapme9nd mmecense GAS PIPE /COOK �C i` YER
1 v_f- `'iih Senion 70007 o n 3 of Ins Business and ornsipny Cad i and my license
Y E J � ,n roll force anA ((sy Ir1/Y�J '
z a ticens Lir.p
3u H nate-' Gommelar
ARCHITECT'S ULCLARATIO
°'O<j mdcrsmnJ my pinns shall h.,.I'd as puhlic records
ad
r
t c e O Licensed Professional
« OWNER BUILDER DECLARATION
w-m1 hereby alffm thin I am exem1-I
pt from the Conualla"a dense Law for the t _t, •,
-Z9 following«sum(Section 7031.5.Business and Professions Core:Any city or county - $1000
.
— which requires a pan d to constrict.after,improve.demolish or isphorany structure - .c
w3� prior to its la momms the rrr t for suchpe ' tone a signed statem - .-. . - . . .. ... - .
todoa iiNterworlpryautt tis provisions olth Cmu to,,License Law Chapter 3A5A4FQ&$AkQ (1 Valuation
leommettcmg x'th Section 71X)l of Division 3 of the Business and Professions Code) `4
or ttiai he is exempt mcrcfmm dnd the basis for the allegW exemption.Any violation
of Section 7031.5 by any applicant for a pctmit aanjects the applicant to a civil penalty R PLUMBING ING OCCU a17C T
t of not more than rise pN-
ve hundred dollar, N P Y yPe
01,as owner of property.ormY'cmpfoye«ails isageaas their tole dompe«anon. 301 - ROUGH PLUMBI G-
>. will e
de'the .,k:.andthe strucfis nm offered for ale Spec7w4.
B.'n.,and fssions Cods'The Commend,, renviLaw doesndt op15 m an mS
.. erof property
Wino ma ofimproves thereon,and who does tam workhimself -506 — GA
through his am provided that h rep < t t intended TE,_ „•-.„ . "
or
'
of ....__
Irrdt tI If,however,m bidding .I.' lewithin' rcar o 507 '" FINAL PLI:JMBING - _
< mplr N Fuld 'llna n n ed fp ' tlsiM1 did tbuldldur f[',J
reprof 'Urtswe
1111,
- lf the property,1Y an,asel.hi,cl, umorchhh,,rth licensed t t .
construct the projei(sed 70,44.B and Professions Cps:)The C at r's
LicenseLawdoen not apply tomi o < ofp > h bu Id. p «threon,
nd. l a contracts t hpail<ts with mntramr(s)licensed p ram m the
Cnm n L Les
❑1ran cam under B C for this reemn
� / . . .. ..
-
-
.I• t
Owner Date /
" WORKER'S COMPENSATION DECLARATION.
.1 hereby off rm under penalty of perjury one of the following declarations:
r/•0,1 have and will maintain a Cinificam of Consent to sel6insure for Worker's
{;. Compensation, as pmridcd far by Section 3700 of the Wbor Coda for the -'
perfamsance of the work for which this permit is issued. -
❑1 have and will maintain Worker's Compensation Insurance,as hequired by Section
3700 of the Labor Code for'he performs f thework for which this perinn is l
s..e W kers Co pc i o Insurance c.0 1.e n Pol icy monflonarb - -'
Cam If C' .. .1 -
XEMY4
CERT FlCACOM OF EXEMPTION RANO WORKERS - -
' COMPENSATION INSURANCE„
( itc union need not be completed if the permit is for one hundred dollars `l -
. 151000 or Is,,.) •. ,
- I n fy that in ibe pert oncia,of the work fur whit th s pbrant is iasucJ 1 - _ - ,. .... .... _. .,. .. .. ... _. .. _ . ...
shall not employ any person in any manner sa as m become subject to the Workers
Compcnsmian Laws of Cabforpla.Date '
Applicant .:.. ...r: - .: .. . . ._ .. .. .. .. .. ._. _. -
NOTICE TO APPLICANT.IL aftennal:ing this Ccnificate of Enemption.you should '
Z baame subject to the W k s Compensation p sions of the Labor Calc,you must
Q Q faith th comply with such provisions or thisp 1 shall be deemed rtvnked
Fh t CONSTRUCTION LENDING AGENCY.'
1 ; 1 hereby affirm ihauhere is a conmmnion lending agency for the performance
'of the x'nrk for wh had this permit'rs Toned(Sec.3()97,Civ.C.)
Q LendcCa Name .. .,. ._ .: ,., .. _ .. -..._. .. .. ...
C,
Leader's'Address
V - I cenify that 1 have read ihls application and state that the above information is '
lar I•., carred.)agree to comply with all city and county ordinances and nide laws relating
Q U to Wilding construction,and hereby amhonie representavveeofihis city m enter upon
.r,C6 the above(We)agree cosmic.oned probe,dfor,ily andion kepmpases.._ _ q
F y eNie)agree m save,indemnify and kccp hm may
in the Cha of Cupertino against
UO liabilities,judgment.,costs rm capons«which may in any way accrue against said
!„) i City in consequence of the granting of this L CO
APPJJJJ�''��77C��'DE S k, SAND II'1LL COMELY WITH ALL NON-POINT Issued by: Date
SOl7>rLFfi.GULATI " . . \ `��—� Y'
Signa�Appl, mX nvactor "„ •I/. Date Re-roofs .
HA/ OU �ATERIALS DISCLOSURE - J. -
i Will the applicant or future nuildinsuc patmre or,handle harardous mmcrial Type of Roof
as defined by the Cupen Municipal Code Chapter 9.12.and the Health and Safety q
Code Section 255320 -
aYs ":I N �
"\ ' - '+ :k. All roofs.shall be inspected.prior to-any roofing material being installed.., ..-
f -
Will tM1 applicant f t Id n t six a. t devices which
pp s w qpm If a roof is installed without first obtaining an inspection,4 agree to remove
smith d nmmm t. s FUd by th Bay Area Ail Quality Management
Ow t all new materials for inspection.. Applicant.understands and will comply with
❑Ye - se - all riori-point source regulations. - - - - -
`/ t i
1 have read the harridan,thilibirm,nqn6brach"under Chapter fi 95of the
California Health&Safny Core,Smtions 25505.25533 and 25534.1 minkr Land that
if the building Jas not currently hale a tenant.that it is my responsibility to notify the
acupam of ere whicM1 must be ma prior to iasoance or a C<nificale of
occupancy.
Signature of Applicant Date
sat iced ase .. Date, All roof coverings to be Class "B"or better
.• ..
OFFICE