01050118 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO
OWNIIR'S NAME APPL1CNIION SUR DATE
05/141POOl
PHONE: SANITARY NO. CONTROL.NO.
OC ARCHITEClifENGINEER: BUILDING 1117RNIIIINFO
BLDG ELECT PLUMB CCH
—
F
Sw i LIC INSEDCONTRACTOR'S DECLARAfI Job Description
OO z E+0 1 hereby affirm that 1 am licensed under provision, f Chap a,9("nour cin.
F�C.wa with Suainn 7(11IR1 of Divisinn3 nfthe Rukber,, larnfecsiom Cr andmylieemse
Is in roll tnrcc unJ cd.? (`
a 1.ian.e clan. J Lie.a_ COPPER REPIPE.
x o a.F Date 3*� .�j conlna,n – +�
w 3 u.,� r nxclt1I4C1'•s IntcLnR, 'I v P(„�b,�
C a.0< 1 nm)cnnnd nr rmn��haB rte n.cd as pnbhc mcoN.
w•�p hiccnscd Ymlcnsional
ea OWNER-BUILDER IIIiCLARATION
el M to, 1 heoby off inn..Ina I n p,re1'mn.flit,Co dnaaar's Licerw Low rnr the
hollowing reams.Section 70313.Bt inns and Pron,,ion,Cole:Any city nr county
S F G which«quireo a permit to comtnmt ulmr,improve,demoli.h,For repair any•tmewrc
rai
Cam prior to hs ism:ma,A...require"Wilppll'unt lorsuch'lourat(olRe a dgned.":demenl
thathe is licensed pursount to the p,avisnm.of the Container,License Law(chaplet 9 Sq. Ft. Floor Area Valuation
pro rein,w.III Stan Ighoof Doi,ion 3of the Business and Profeeaionn Code)
I,,ded his car III thi..r and the basis for the alleged a alf,don.Any vielon
of Semon 7031.5 by any applicant fol.Pomo,subjers the upplicam m a civil penally
of nafim.rc(him five humheddalhns(SAa1). APN Number Occupancy'type
01.aa,rvnerofthe property,or Illy employers with wages as their side cuntpenca,ion. Otifh
will do Ilse work,and the sma one i,nut uncorked a offered rot lute IScc.71,44, `-
Business and lhnfecsion,Co acense Code: Contranr's Lilaw,does not apply For an Required Inspections
w r of property Who huild%nr improv..therwm,and who docs such work himself
or through 1, is own empluyeca.privNod(bar inch mmmvenen,are on intended ur 202 — UNDERFLOOR PLUMBING .
offered for Sala If,however,the building or improvement is sold within one year of
inmplalimn mcawrc,thrimer,w ill have me burden(if proving that he did not build or X01 — ROUGH PLUMBING
mprove Fort'an"we of kme.)L
❑1.toowncrtrill ep..... t”.our aaata,ivelyemnnleangwith Banwdcontractors m 02 — FINAL PLUMBING ENERGY
construct the reopen(see.Two.Btsiaess and pmre..too,eodeD'rhe Lantmenr's 7 — FINAL PLUMBING
License law docs not apply nr an owner of property who builds or improv%Bacterin,
and who conlocl,for inch No',ets will,a oarnamr0) rmcoscd .uduart an the '
contractor,Lian.e law.
❑I ant corolla under Scc. .B&1'C for this tenon
Owner hate
WORKER'S COMPENSATION DECLARATION
I hctchy unionmaiJct peealty of p jury one..(the fallowing declanJom^ ,
❑ 1 have and will ntain corollate of Consort for xlf-insure far Worker's ,g I
Compemation. its provided for by Section 370K) of the Labor Code, fill the
pedimname of the work lir,which(bis larntif i.o,tord.
❑I have:nd will naimain Wnrkcr's Co..i,malion le,mat cc,as required by Scrim •✓ • .�
3700 of lite Labor Code,for the poll an" of the work for whldt thin Penni,i,
iso
,it sly"'oder,Compensation Insurance c and''ppollVi'Je numbera are
Coni r. CE-e N F1CA�nO.N OF 13XEh1Pfl ^e FRO1N'ORKIiR1' I "
(46A'L(ekyCOMpENSAI'[ON INSURANCE
(this section need not be completed if the permit is for one hundred dollars
(8110)or IcasJ
I ecrtify that in file performance of the work for which,bis permit i.issued,I
shall nm employ any person in tiny mato,, ,,nom Free nme-uhjea in In,Workers'
compensation laws of Ca romia.Date
APPllctint
NO)ICE9'0APFLICANT.11:afler(nuking this Cenilicale(I1 Exemptinn,You should
hsome subject u1 the'Voder,Cral..tlon provisions of the Labor ChM,you mint
Q O Iimhwida enmply with such to.ov..ionour 1111,pe if shall be declined ra,okcrl
r CONSTRUCTION LENDING AGENCY
' I booby union(hill then is a con.lmaion Imtdmg agency In,the pernmaanec
fol ...the work for Which this porton is issued(See.oar.Civ.C.)
O. 0 Lender's Nnno
Z Lender',AJdre,s
U 0 1'coil,that l lon"ne I 111,uppll'atlon and lam Thal the ubuvc Infomtmion is
Iz (..I enunion.I agree to comply with all city and county urdi...so and.ante laws refuting
Q C.1 to building comltuction,and hereby nntherire representatives ofthis city to enter upon
the ors vw...rad ancd......tiny for inymYiun purpuwn
F y lits)agree to save,indemnify and keep Imi the City of Cupeniw again"
V) Iiuhllitim,judgnwn,s,costs and ex.crws which nay in any way income against said
U G City in cons quctac of da......Ingot leis..coot. �^
APPLICANTUNDBRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedb �4 DateJ��
SOURCE REGULATIONS.
Signature of ApplicaWConmcm, [)ale R, roofs
HAZARDOUS MAniRIALS DISCLOSURE.
Will the app! or(lean building,*'evpam anrc orhanJle IuvuNous inertial Typc of R
1s deli tied by the Cupertino Municipal GNe,Chapter 9.12,and the Health and Safety
Code.Scotian 23532(all'
E)Yes GNo All to s shall be inspected prior to any roofing material being installed.
Wiif the upplion",or I uturc buildingoccupunl use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
mnit hazardous air contaminants m defined by the Bay Area Air Quality IvEmagemcr,
Dikmea7 all new materials for inspection. Applicant understands and will comply with
ClYe, DNo all non-point source regulations.
I huve rend [at bueurdous m.1,6al......rentonas alley O up"h,9.of the
Cali fomia Health&Safety Little.Sections 25505.25533 and 25534.1 understand,hal
it the ht"It ng dues not cunenaly have a an:mt,than a is my responsiniltry to mildly the
occupa of c rc i nenls which muss be tact prior to Usuanm of a Cunilicme ill
>` C 1�( Signature of Applicant Date
own—rmamnan, enl Date All roof coverings to be Class "B" or better
OFFICE