02100195 CITY OFCUPERTWO s �'" ' i 'mF ''' ' '°
BUILDING DIVISION PERMIT CONTI2AOR�NF'URMATTON
BuEWINGADDRFSS: NEW STRUCTURE PLUMBING INC PERMIT NO 02100195
OWNER'S NAME: P.O BOJ{ 111145 ""f8AAO/2002
NE' (408) 364-2145 SANITARY NO. CONTROL NO.
ARCHITECDENOINEER; - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oip LICENSED CONTRACTORS DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(eommcming P
<S withS don7=)of DM4on3ofth)Businev Pmfrssiam Co&.mdmylicm is
< in full faro end affm
^gz
Dan-
License Class tronas COPPER REPIPE
ARCHITECTS DECLARATION
I msen and ney plena shall he used as public r)emds
7y
is Licensed Pmfenion,l
OWNER-BUILDER DECLARATION
v� I hereby.(Sero I am exempt from the Cantons Co Ucense Law for the
x p O following tchra moron.Permit
(Section 703 L5,Business and Professions Code:Any oily or county
g which requires a pmmit re cnnswcL eller.Improve,do nt rorsuch permit
t m e pair any tatucmm
S° thprithe its issuance.purse require the inion nfilm Conaretaitm manse igned Law
pp x�xQ (Comm) licensed pursuant Ed Mai provisions of the Comrsimfa Lbcnselsio(ChaptersCode) 9 Sq.Ft.Floor Area
je Met M I.exempt
with Section]and bulsof r th Al Busiegad Carn d Proon.Anymm Code)or
of
Net he b txempt h....from and the bub for that Alleged caemptim.Any violation of
Section 7031.5 by any applicant fora permit subjects Me applicant to a civil penalty of 3 M194-bittlDer 0 0 Occupancy Type
not mom dun five hundred dollars(M).
❑Lo owmr Oftnephepmty.mmYmimanenwithwagu reale(ce.cempenudm,
wits Pr thcwon end The Com usuce,Lt. Law it.
r .1 apply 70An owner Of _ @'d'�TTT(p'
And Profession Code:The C stioneon,License ms dors not apply lf rt owner is UM HBA
property who bulldamimprovmtherton,end whodcesamhworkhimsel(orthmugh lib 301 - ROUGH PLUMBI
ownemployces.provided Matsuch improvements..at lnwndrd orortered inial..If. 502 — FINAL PLUMBING ENERGY
however,the building or Improvement Is mid within am year of compledon,Me owner.
builder will have the hurden or pneving that he did not Wild or lmpmw for purpose of 507 - FINAL PLUMBING
u[A I.
❑1,u Owner of the property,Am exclusively conumOng with licensed contractors to
construct Me project(Sec.7044.Business and Profession Code:)The Conuacmr's Li.
came law dao nal apply to an owner of property who builds or imphews Maroon.and,
who contracts for such projects with a eonusnor(s)licensed random to time Contractor's
License I.w.
❑l am exempt under See .B&PC fm this mann
Owner Dau
40 WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of de following declarations:
1 have and will rmi nalln a CcnifiWto of Consent to self-insure for Workes
As provided for by Section 3700 of de Labor Cade,for the performance of The
work for which this permit is issued. .
❑I haw and will maintain Wmkerlanteofthew Insurance,h required by SC Wood, "
0 1 of the aLabornd
will
Code,for the performance ep Compensation Me work for which this permit is cued,
My Worker,Compensation Insurance omen and Policy number are: e
Gertner. Polity /
CERTIFlGTE OF EXEMP0N FROM WORKERS'
COMPENSATION INSURANCE
IThbmeNm reed set be Completed if the Permit is foram hummaddoltars(SI00) 0
m krs)
I cenlfy that In Mc pmformance of Me work(or which Mb permit is issued.1 shell not
employ any person In my manner m As to hecomc subjccHo Ile Workers'COmpensadm
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenincate or Exemption,you should
become subject in the Worker's Campen>°etion provisions of the labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed rewked.
Zti CONSTRUCTION LENDING AGENCY
[—d 1 hereby effuse that then its consuuctinn lending Agency far Me perfunnence of
�i > the work fur which this permit is issued(Sec.3(19],Civ.C.)
WQ LeMi.e.Name
W
7 Z Lcnderi Addrms
()Q 1 certify that 1 have and Mia application and mute than the)now infra nothm b
W U canecL 1 Agro to comply with all city and empty ordinances and slow Taws m W ng to
O Wilding construction,and hereby mthance representatives of Nis city to enter uPnn the
W shave-mentioned therapy for inspection purpm)>
fY (We)agree to saw.indemnify and keep homeless the City of Cupertino against
wy Lol limilides.judgments.emu and expcuu which may In my way aceme against mid City
() in^' s arb.
APPLICOof the grinning or tND
ANTUNDERSTANDS AWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanlDow
HAZARDOUS MATERIAISDISCLOSURE Type of Roof
Will ft applicantMur futureipal ation,or Mdleh Health
and Safety As dented d de 32(ay? Municipal Code.CluPmr 9.11.and the Health and Safely
Code.SeNu1ss31(a)7 All roofs shall be inspected prior to any roofing material being installed.
1 ❑Yns ONO
Will in.m applicant in future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
.nit District? m oiropnlominsnts u defined by Me Bay Area Air Quality Managcmcnt all new materials for inspection.
D'strict7
❑Yes ON.
I have read the hmardms materiels requirements under Chapter 6.95 or Mt Califon
pia Health&Safes,Cole,Sea..25505,25533 and 25534.1 undcrslond Metlithe binding
it=not currently have a enan4 that it is my mpensibillty,to ratify the occupant of the
requirements which must be mel prior to iuuancc or,Certificate or Occupancy. Signature of Applicant Date
Owner or mmari.<d agrpt oaw All roof coverings to be Class"B"or better