01030033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUII.I)INGADDRF.Sj.'08`2 WILKINSON AVPERMITNO.
CUPERTINO PLUMBINIC
010300=3
IIWNIiR'S NIAID: APPLICATION SUR DATE
LEARN ARTHUR w4. AND BETTY X 1.0297 S DE ANZA BLV 03/07/200
PIJONl4 SANITARY NO. CONTROI.NO.
(408)283-0618
OHO ARCllfl'ECI/ENGINIililt - BUILDING I NylsTINFO
w BLDG ELECT' .UM1 MIiQI
Fru I= J
S�j I.ICLNSEDCONTRACIOR-SDLCI.ARATION Job Description
=0 1 herchy affirm tbm 1 am licensed under pnrvisions of CTapar 9lcummen.ing p
Eo. is in conn]Iinit ivlxiunJ til lire ltueinesn unA Pmfcreinns Cndc.and mylicanm
�x� `1nscchos, d `" Z REPIPE $ WATER SERV E.
Dna_ Camruanr —off
CLL 5 l understand tip' )an,shall bo nwd a.ptrnlm record. '
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a6p� LceIP 1 ': 'I
OIVNi R II UILDI:11 DI LI ARA(nC �/�
i m I h b R m th 1 1 pt f m the C tra I l for the
F t;� follow g .(Section]BJI s R s
cs I I I: ns, J Any city or county
ASO .1t.1 y l mill 't 'thchi cw,rhucok,l I any:vuutire
ae
n3e�2 prior I,its issuance.also aquire%theapplicam for such recur to file a signedl.slaurnant
that he is hared lm..an,to the provisions of the Contra.vds License lw(chapter 9 Sq. Ft. Floor Area &Iuation
(commencing with Sei,ion YIXXI)of Division 3 of the Brinc,v,trust Profession,Gde) V
nr On he Ls exempt Iberct mn.and the Kok Thr the alleged eaen,p,lan.Any violation
of S¢tion](IJLS hY troy applicant for a pemnit nuhjecu the applicam m a civil penalty
of na mom,oath etre namrw anlwra asap. APN Number Occupancy Type
01,as owner of propeny.(it my employees will)wages a,wir enle rompen.atinn. 3561 3037. 00
will du the work,and the snunurc is not intended or offered for sale(Sec.T)Ll.
Ruvine..and Prufes%ians Code:The Contractor's License Law(tire%oat apply tis an Required Inspections
owner of,ropvdy Who hada,ur 4.u, cs dweon,and who does eon,work hi,rclf
ar through his own employees.provided that%ucb improvements are not intended or 202 — UNDERFLOOR PLUMBING
of ered for sale.IL however.the building or improvement is sold within one year of
mpdo,ion.tlnc owner-nnildcr will have the nunen ofpmving this ledid not huim u, 301 — ROUGH PLUMBING
inpr'wefor pr,werfan'`) 502 — FINAL PLUMBING ENERGY
D 1, is owmr of the property.nm exclusively contracting with licensed connannrs to construct507 — FINAL PLUMBING
the Inojecl(sec.]MJ,liconcs and Proev,iuns Code) he Cnmmanr'n
License Law dues not apply to un owner of,r.,edy who Nilds or improves(hereon,
and who contracts for such projects with a cont ructuds)licensed pumurnt to thn
Cnn ra"'n'n Lieunsc Law.
01 ran exempt under Sec. ,B Ft P C for this reason -
0191eI D:nc
WORKER'S(OMVITNSATION DECLAIM ION
I hereby affrin tinder penalty of perjury one of the following declarations:
0 1 have and will maintain a Cenificate of Consent to self-incur`lior Wader's
Con en.mtion. as provided for by Section 3]00 of the Labor Cale, for the
,Murmame A the work for which,hiss permit is issued.
01 have and will maintain W..om's Compen alion Insurance,m myuiml by Section
3701 of the I.uhor Cale.for the performance of the work far which this permit is
sued
9y oryo 6cr.Contperntlnn b,xuftuwe currier and Palley......the,um:
.urrim: L pol Na:w-NZ_TRS
CI1R'I'IIlCACONI OpSNIION INS RANO WORKICI25'
COMI'L'NSNIION INSURANCE '
Opti,svc tneed nut he ciondemd if the permit is for one hundred dollars
(V lml or less.)
1 certify that in the lerformanm of the work for which this permit in iswed.I
shall out employ m,y pcmon in any amu no,so us ,,become subject to be Workers'
Campenwtion Laws of California.Date
Applicant
Nf nccL 10 APPLICANT:11,after making this Ceoricmc of Exc.nuirn,you should
Neo
c . c.rr,, to,he Worker',Compensutino powiciona
x t tire m
e I,Ntu
r Code,youno
Q O forthwith comply with such provisions or his permit sN11 be deemed revoked.
L� CONSTTIe is acorNLENDI NGfir, en e
J I heresy%inch this(here 4.,s amsd(Sec. lending agency fin the fetlimnan¢
fine Cora for which this permit is issue)(Sec.J(MA.Cie C.7
6s ^Q Lcnder's Name
7 7 Leahr',Address
U O 1 redly that I lure rend this apdication and smtc than the above imf...nation is
W �y aa...1.1 ig,cc u,nn....1,will,ill cly:sod county rnucones:aal.ran laws relating
O C.1 mNildingcondroction,and hereby aulhodeerepn...aloes ofdoi.ciy loco,upon
} the above-mentwned property hu inspection purposes.
(Werallow III save indemnify and keep burmlcs the city of Capenino against
h liuhilitin, osts it expcnsa w ,y In tri - e%gains,raid .3 -7 -70/
U Z CID'in mmeyucnce of the bran inF fit.
SII. CLR C.NDIiR. ..D I C PLY WITHALL NON-MEW Issued by: Date
dnnmr �n intra — Date Re-roofs
1,•.ARDOUS NINI'IiR1ALS DISCLOSURE
,n the applicam ur mi,m htmdmg amop:mt,tire or handle hn,amli o material Type of Roof
as defined by the Cupertino Municipa�Chapter 9.12,and the Health and Safety
Code.Section 2553211T1
ElYe, All roofs shall be inspected prior to any roofing material being installed.
., Will the applicant afmmm�aaai rnpanttr,ecyaiprent ordevices%hich If a roof is installed without first obtaining an inspection, 1 agree to remove
mit lwz:mlow air cum;1....u.. ,W M1y the(lay Arcu Air Quality Managcmcnt
Dlsmict] all new materials for inspection. Applicant understands and will comply with
Dris 0N all non-point source regulations.
1 ro,read,hr.hamr.bms,It mals mynimmmrts anter Cul,er 695 of Ne -
Culiliomia Heald bot Safety Cale.Sections]5505.8533 and 25534.1 understand that
iflhenuddingdeesnotcancnd nor. ant.Henn' res,on,flua,ur notifythe
of Ise m.nI dch ben or en issuance of a cemihcae of
Acc:ijro,
cupSignature of Applicant Datc
x—r nm i,dg—„t D„m All roof coverings to be Class "B” or better
OFFICE