01110044 CITY OF CUPERTINO I
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21820 WOODBURY DR CUPERTINO PLUMBING 01110044
OWNER'S NAME: APPLICATION SUB DATE
FOREMAN GLENN L AND ERMA J 10297 S DE ANZA BLV 11/07/2001
PHONE: SANITARY NO. CONTROL N0.
(408) 253-0618
"WEARCHITECTIENGINEER: BURRING PERMIT INFO
0
m E BLDG ELECT PLUMB MECH
t L_I I"_.I LJ L.1
2 LICENSED CONTRACTOR'S DECLARATION
-5 ? Job Description
wi
I Z= I hercby aRw thn 1 am licensed under provisions of n,Code.
(commencing
v,tu) Ngeclion711110)ofD3ofthe Business endProfessionsCade' i'on .undmylicense COPPER REPIPE, WATER HEATER, WATER SERVIC
C`y5 is in full forcer 2fc -\�
R
C 6 License Class
Lit.g V
3 3 W H Uam Contract
p, AR ITECT'S DECLAR TI
a Pj 1 undersand my plans shall he used os public rcco s
�-ooaf
Licensed Professional
o
a OWNER-BUILDER DECLARATION '
=m 1 hereby affirm that 1 am1. .Barone from the Contractor's License Law for the 5
foil ing requires
a (Sectiont ]0715 Business and Profesunss Code.Any city st county 0 0
D wince regwrcs a permit m construct,alter.Improve,demobsh o rtpatr any structure
p t m t caul req ate th isimsa to Conn &soi kwUe(summers.•
Nath n f . it pu¢w nd the pro ions of thr C e Bust r L Genu law(Chant«9 f. ' cp , r a i r Valuation
(commencing is with Section]000)of Division J of the Bust N p irt.Any
Code) t ;-h t )3 Zp' lJ s%-r:;,'IT� 3�`:'r ern Ii 1�J.'�
or Net he is eumpt any cep li and the basis for be alleged ptr Any l Penoan i
of S«don lOJ IS by any applicant for a permit subjects the appliant m a civil perWry
of am name the.five hurdred dollars($.W). 202` PN�. FLOOR PL BING Occup aney Typ e
°I.u owner of the property.or my employees with wages as their sok compevvtion,
will do Ne work,and the swctme is not intended or offered for We(Sec.]D44,
Brameu and Professions Code:The Conuacmr's License law does not apply m an 502 - FINAL P2104Wi1499spEX8F6GY
owner of property Who bunds or improves thmeon and who does such work himself
or through his own employees.provided that such improvements are nes intended or _ 507 - FINAL_ PLUMBING
-offered for sale.If.however.the building ar improvement is sold within one year of -�- - - - -
completimi the owner-builder will have the burden of proving that he did not build or
improve for impose of role).
`co L tr ct the of the prone.,an
Business a convecting with licensed contractors mconstruct the project(Sec.7004.Business and Profusions Cade:)The improves
tmctols
License Low tract not apply man owner of property who builds or seimprove thereon, t
and Comoro convents L such projects with a comncmr(s)licensed pursuant m the
01 a m exempt
License Lew.
❑lam escmpt under Sec. ,B&PCfar this reason
Owner'
Date
WORKER'S COMPENSATION DECLARATION
' 1 hereby effw under penahy of p«juiy one of the following dedareuons:
O I have and will maintain a Certificate of Conant to self-insure for Worker.
Compensation, as provided for by Section 37W of the labor Code, for the
performance of the work for which this permit is issued - ~'
1'
°1 have and will=]main Worker's Comprvuion Insurance,as required b Stion - _-
3]W of the labor Code,for the pellormantt of
the workpermit
for which this ec
is
Worker's
isamek'My Compensation Insurance c er and Policy number are: - -
�d fin+ C I y o.: 3 p
CERTIFICA N OF EXEMPTION FROM WORAERs'1 L :.i'` a l<:f
COMPENSATION,UISURANCE ;,`}'_ ' _
(TAis section tired tot be completed if the permit is(n ave hundred dollvs
4100)or bass.)
'f I'cerify Net in the perfaimmKe of the work for which this permit is issued,1
ihall not employ any person in any manner so as to become subject w the Workers'
Compensation laws of Cellf tow Data
Applicant
NOTICE TO APPLICANT. after Compensation
Cisions fIh y haul
Z
became mbj«uo the such pr Colons or thin Prov stank of th btu Code, 1 t
O O forth nA comply with such pro Bions ar this pew t aheil be ed't.1 okM, t• --
2000
CONSTRUCTION LENDING AGENC
a 1h In
Bloat dt there uocans is le d' gegn for the perfo t
a',
f thework fgsoh ch that pews is issued(S iW7 Civ.C)
W „
(� Lend N.M. .• ' - ... .
yy LeadW,Address' - z• �,
0 1 minify that 1 have mad this application and state theuhe above mfom ams is -
fat Ey tyre(.1 agree to comply with ail city and county ordinances and sum laws renting
Q (, to building construction,and hereby authorize representatives afthis city to enter upon
W the above-mentioned property for inspersion purposes. _ .
.On (We)allies m ave,indemnify and keep hawku she City of Cuprrino egsimt
fq liabilities,judgments,costs and expenses which may in any way acme against said
C.J City i eq encs of the gran ing of Nis permit. -
APPI CAl ND S' ND.IAND W ILL COMPLY W ALL NON-POINT
sats T 6bA n . Issued by: Date
l�
Signature of Applian✓C atm Date Re-roofs
waw or TERIALS DISCLOSURE
Will theapplicantm(courtipal Co occupantstore2.namkn:;.rananmaurim Type Of Roof, -
u ds,Sed by the Cupertino Municipal Code,Chapter 9.12.and the Health erd Safety _ V
Corfu.Section 235321x1? .;. "a -...:: \f. i f l.�`• '.3�: ' n-:a•.
°Yes ON. „ . .All roofs.shall.be inspected-prior.to.any roofing material being installed.
AM Will the applicam or town building occupant use equipment ordevices which If a roof is installed without first obtaining an inspection; I agreeV remove
emit hmudoue air cnmana menu as defined by the Bay Asea Air Quality Management
Dirt ni all new materials for inspection. Applicant understands and will comply with
°yC6 °" all non-point source regulations...,
"I'have noddle haznNous matcdsh requirement'under Chapter 6.95 of the
California Health&safety Code,Sections 25505.25533 and 25534.1 understand that
if the Wilding docs not currently have a tcnam,that it is my responsibility to ratify the
ac ant a the r lute a which,must be met prior to issuance of a Certificate of
Y I' cupun��
_�1 Signature of Applicant Date
Owrrroriwdm!nzm. t Date All roof coverings to be Class "B"or better
OFFICE
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