04010099 CITY OF CUPERTINO
BUILDING DIVISION - PRRMIT C� .RLiT�ll Ll\i'�;14�M� �1V
BUILDING ADDRESS: CUPERTINO PLUMBING PERMITN0.04010099
OWNER'S NAME: PERMIT L%UE DATE
LYNN FULLER
ONE: SANITARYNO. CONTROL NO,
(408) 253-0618
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
um C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
n<i with Section 7(KXf.r OlvvionSof the Business and Professions Code,and my license is ,
lq, Lifull McCleonacH__. lo2Ygi0 COPPER REPIPE
g to Licenu ass Lk.N
e F,a Dam �-'/i - Cuntmcwr
(under a/f D�,ARCHCr& A 1
nd My Pk,uaITE
, I bap iPu I - PINALED
01 Licepacd Mn mon
S OWNER-BUILDE CLARATION FEB 2 4 2004
It. y affirm that 1 ore exempt Gum c Cnnbacmr's Liccnsc Law for the
E o O following reason.(Section 7031S,Business and Professions Code:Any city or county
$ which requires a permit in construct,slier,improve,demolish,or repair any structure
_Zv` prior m its issuance.also requires the applicant for such permit to file a signed statement
EZ� that he is licensed p.omenn.the pmvisimxnf the Commuter's License Law(Chapter 9 Sq.Ft. Floor Area
But 1011000
%t (commencing with Section 7")of Division 3 or the Business and Professions Code)or.
y 3$ Nat he is exempt Nerefmm and the basis for fee alleged exemption.Any violation of s
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 iIl��TWerOO Occupancy
notmom than live hundred dollan($500). p y Type
❑I,as owner of the property,or my employers with wages as their sole compensation,
will do the work,and the swcture is not intended oroffered forsale(Sec.7W,Business
and Professions Code:The Contractor's License law does not apply in an owner of Required Inspections
property who builds or improves themon,and who doessuch work himself orshmugh his
own employees,provided that such improvements are not intended or offered forasle.It.
however,the building or improvement is sold within one year of completion,the owner.
builder will have On burden of proving Nat he did not build or improve for purpose of
Cl 1.as owner of the property,am exclusively counting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li.
cense Law does not apply to an owner of property who builds or improve thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to fee Contractor's
License Law.
❑1 not exempt under Sec. ,B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Oc fallowing declarations:
I have and will maintain a Ceniricate of Consent to self-insure for Worker's Coupon.
action,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 or the labor Code,for the performance of the work for which this permit is issued.
My Workcra .mm mstio n¢unna Carrier ad Policy number am:
0
arc: ,'r
Cartier. IP ✓/N/ Policy No.: OC)
L
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not becomphied if the permit is format,hundred dnilana(6100)
or ass.)
I certify that in the perrormance of the work for which this permit is issued,1 shall not
employ any person in any manner an arm become subject o the Workers Compensation -
Low of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwi N comply with such provisions or this permit&hall he deemed nrvoked.
.z., "I CONSTRUCT]ON LENDING AGENCY
[-. Thereby affirm that there iso conswctinn lending agency for the performance of
FG the work for which this permit is issued(Sec.J097,Civ.CJ
f67 La lender's Nam.
zz
Lender's Address
U Q 1 certify Nat 1 have read this application and sum that the above information is
U. F COCCIL I agree 10 comply with all city and county ordinances and state laws misting to
C)U building consquctimm,and hereby authorise representatives or this city to eomrupnn the ✓/(/��/ (/
z shove-memimnc0 property for inspection f-maivosea ( Y l
gys (Wt,)agree 1.save,indemnify&adkeep harmless the City of Cupertino against
,.y N Iiabilities,judgibee Teets dcapensrswhic may in any way acme againstsaid City
(„) '� in cmrtsrq mo, 6 ting of thi Pcrmi
" APPLIC D STANDS Q.W - COMPLY WITH ALL NON-POINT Issued by: Date
SOU ONS.
6 Re-roofs
n re of AppiicamuCnnm Dow-
2r,
am
2r, HAZARDOUS RIALS DISCLOSURE Type Of ROOF
Will the applicant or low.b 'Iding oampant time or handle haserdous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
ode.seam,l5su(')7 'All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant Use egUIPmnnl or devices which If a roof is installed without first obtaining an inspection,I agree to remove '
it havaNnus air conmminanm as defined by the Bay Are Air Quality Management all new materials for inspection.
ixtrmt ` ,.,n
❑Yes 'D+9 17
I he.(cad IN.. jusm rials, uir....m.nder ,Chapmr6.95ofthe Califor,
Dia HealN&'g.re Cndc, now A)5.2 33ard25534.1undersmndthatifdm building
does not c y wt
n'a 'ar it t "sponw sihility nodl'y Oc occuPsm of Ne
requircor ( - pctw.11ccrdficaueo Occu mcy. Signature of Applicant Date
arm awhorivcd agcy Il Data - All roof coverings to be Class "B" or better
CITY OF CUPERTINO o 7
REPIPE/SEWERS/MAIN SERVICE b T l
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
X24. yL . bl 1 21
Building Address:
S � Gal'�i r ✓1C�
Owner's Name:/ Phone
U /C�
Contractor: Phone: License#:
Gv o lv_m ln z aC� & 2 US
Contact: P ne: Cupertino usiness License #:
�k Calms S 3 0� eco z
Bu' rmit Info:
ildgS�ZElect ❑ Pl mb
Jo ebroer-
Residentialsidential Commerci ❑
Cost of Prcje7 ��,,,,,), _
Qty. if
A Fee fD Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFD{TURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING