01100074CITY
DVONO
IiSIiNPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
19743 WINTERGREEN DR
CUPERTINO PLUMBING
01100074
OWNER'S NAME:
APPLICATION SUB DATE
DUDLEY STEPHEN W JR AND HELEN
10297 S DE ANZA BLV
10/10/2001
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PHONE:
SANITARY NO. CONTROL NO.
(408)253-0618
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ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
]Ob Description
1 hemhy offror that I am licemed under provision., of Chapter 9 (commencing
P
to
with Section 7")of Division 3oftheBusiness eadProfoai ... Code.andmybecia.
COPPER REPIPE.
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is in full force and efrppcc!!3�/r t C
T / US
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License Class tic,a _2
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Dam It rrJ- f Contractor
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ARCHITECT'S DECLARATION
I understand my plans shall t e used as public records
OLicensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt tram the Cornmeters Li ens Law for the
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following reason. (Section 7031.5, Business and Professions Cade: Any city or county
improve, demolish,
$5000
-,nortoits
whkh requites a Permit to construct, alter, or repair any structure
mrm.
uce,elsorequiresmeepplieem fanner permit lofleasignedsma
issan
.... _.._ _. _._. _ _ _ __ _ _____... _-----_
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-
mast he is hc<nsed pumuddrto the prbviziom of the Conwcmrs License lsw lChepmr9
(commemorating with Section 7000) of Division 3 of the Business and Pmfessims Code)
..",. ,.. ��J /��p a•r'• s',, Valuation
(_'e t.'•'�°�:j'J ''
or mat he is eaempi therefrom and the basis for the alleged o&mpdoe. Any violation
jJ,tk..i,i �
of5cction 7031.5 by any applicant for a permit subjects the applicant o a civil penalty
ofnon mor men rive hundred dallsom0om
�.�k,���� Occupancy Type
PNUNL
202p kFLOOR PLUMBING
O I, m owner of pmpeny, or my employees with wages as their role compenution,
Will do be work, sand rhe stmcture is not intandcd or .pored for sale (Sec. 7034,
Business and Professions Coda The Comtacmr's License Law does ata apply to an
502 — FINAL PLR9NHBT0Ti9sFS13i9RiGY '
owner of property Who builds or improves thereon, and who does such work himself
or rough his own employma. Provided thea such improvements er< pm amended) ae
507 — FINAL PLUMBING
-,
offered far xal<. If, however, the building or improvement is sold within one Yam of
- • ,
the owner -W ildcr will have the burden of proving that he did not build or
iompletion,
mpacts fee parpme of sale.).
❑ h u owner of me property, am exclusively commeting with lien<nsed canvanms w-
omuuct the project (Sec. 7034. Business mid Professhow Code:) The Convector s
License Law docs not apply,. an owmr of prop<rty who builds or improves lomerm,
end who mnvams for such Micmac with is comramags) licensed pursmm to the
Convenors License Law. .
olamexempt under Sec. ,BIII PGfor this rexan
FINALED
Omer'' Date
WORKER'S COMPENSATION DECLARATION
%,
NOV 1. 3 2001
l hereby infimr under penalty of perjury one of 11 following declarations:
imn a Camfim¢ of Consent m sdf-ansae fm Worker's
3omI haand eai
pcmote tion, -as wail mprovided for by Section 3700 of the Labor Code, for the
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performance of me work for which this permit is issued.
BUILDING
O 1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of the Labor Code, for the perfamance of mae work for which mix permit is
'd M Wrssu
I eCompensation Insurance carrier end Polinumber �m}'
mRTIFICATIONOFKEMPIONFROMWORKERS
Cam pil No:W�'
I sS!:'•. `J1.ty
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...�., .. -„ COMPENSATIONINSURANCE',.:...:.. •.'-
....._....._._._... _.__.._..__...�.,.,._. __.._._ __._..__.__.. .. ._.._ _ .. .. ...._
(Thisaction need not be completed if the permit is froom hmMred dollen
ss l7 \ '� r" h.. •• t s -'., � .', •. •, (. '
IS 100)or less) ,
1 mmpl Out in the performance nn Ne fa whirls man permit a issued, I
as t
shell not employ any person in any manner so as m become subject m mac Workers'
Compensation LawsCallfamie: Dern
Applicant .-
NOTICETO APPLICANT. this Cenins of Latior iod....norld
o ra,
becomeh the Worker's Compensation pmvix sof theemed Coda you must
Warker's Co CompancRensation
(onhwith comply with such provisions or this permit nfiell be deemed revoked.
comfy
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' CONSTRUCTION LENDING AGENCY
I hemby affirm that mere is a construction lending agency for the perfomtance
of the'work for which mals permit is issued (Se. 3097, Civ. C.)
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Lenders Name' -
_ - -
Landers Address
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,.1 ttnify that I have read this application end state that he above information is
'
correct. l agree to comply with all city And munry oNit ares and s,am laws relating
to Wilding construction. and hcrsby authorize repascmatitva of this city to enter upon
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the shove.mentioned property for inspc aio pmpaws.,, , ,
e
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(We) agree to sive. indemnify and k miens the City of Cupca ino'against
c�ch
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in any waY eccmc agaimt vid
Habilitim, judgmental, ensu and Islajudgmems, mea aspen m in arty way acme agaimt said
iCity
;
in consequence of the gm mi sperm' '
UN t DWILS PTIM1r'Al.t'NON-PoB4T''
Issued by: Date
y:
S n�APPLICANT
' /U- lO- O' /U- lO- U
Sigwmrc ofA r HA ROOD'
'HA' Oum MATERIALS
Re -roofs
somorSURE
meappfmnlmmmrcbadamgmcapamxtarcarnanalenararaaaamamdal.
Type ofRoof
asdeamd by the, Cupertino Municipal Cade. Cheprer9.Q. and me Health and Safety
Ballon 25S33(e)7. Vi,Y',
.a r `'et. d•t •.•:j•
C, •. etil l.: �.
Code. ,i f: .. .I the .a,`•..
0yes, + " ' '", 0 N
•'., ,. L• a f..r' ..
All roofs shall be.inspected prior to any roofing material being. installed. .
• Will the applicant or future Wilding acupam use<quipment or devices which
If aroof is installed Without first obtaining an inspeetioti;I'agree to remove
emit invocations air comm inerts as defined by the Bay Arca Air Quality Management
DisWmo
all new materials for inspection. Applicant understands and will comply with
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all non -point source regulations.
"T hive read the towbars memriels rcquircments under Crep<r 6.95 of the
'
Califomia Health & Safety Code, Sections 8505, 25533 and 8534. I understand that
if the Wilding does not comedy have a mwn, that it is my responsibility to notify the
acupam of the requirements which most .be met prior to issuance o(e Certificate of
Occupancy... .. e .
'
Signature of Applicant Date _.
All roof coverings to be Class"B" or better
Owner mauthndzoieage., Data
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OFFICE
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