02110160 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAOTOR INFORMATION: '1
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BUIL IS. PERMITN(02110160
owNFARAMDY SHARON E TRUSTEE APPLICAT'(4"ATly2002
'ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
�00LICENSED CONTRACTOR DECLARATION
w— 1 hereby aremt that l sm licensed under pmdsion.of Chapter 9 kummenemg COPPER REPIPE Job Description
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in m0 reean�'J��,�r«$,m �/' '�O �LEARWATER PLUMBING
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ow u undcrwnJ mY plans shell W Decd as punlie recons P r..-, DEC 1 2 2002
LLo� Licensed Pmfcasional
as
OWNER BUILDER DECLARATION
C <Y1 hereby affirm that 1 am exempt from the Contractors License law for IM BUILDING
w p o following mom(Section
il. 7031.5.Ron.and Pr fee iuos Craft:Any city m coumy
n.w s E� which requires a permit to ct�eruct,allot improve.demolish.or repair any swemm $4350
F>s prior to its isvwnce.alit)"U1rcr the applicant for such permit o file a signedmaement
€zo
that Ito is licensed purstratin to the provisions of be Conossuctiou'r License Law(Chapter 9 Sq. Ft.Floor Area Valuation
yt— (commencing with Scetion7")of Division 3 of be Bwim..arta Professions Cude)or
c $ that he is exempt thenefmm rand Be hada for led alleged exemption.Any violation of 31631012 . 00
Shomm 7031.5 by any applicant for a permil subjects the applicant to a civil Nulty of APN Number
not mom Bareewhundreddollars(S5m). 202 - UNDERFLOOR PLUMBING
Occupancy Type
0 I,az owner of the Property,or my employes with wage as their sole compensation,
will an ted work.ark tlx:structure is not intended or offered for We(Sec.7000,Business ¢
if
and Professions Code:Tac Catatm aran,License law does not apply w an owner of 5 0 2 - FINAL L MGM RGY
progeny who builds or improves thereon,and who doessuch work himeolforthrough his
own employees.provided that such improwmenes are not intended oroReredInstitute.If. 507 - FINAL PLUMBING
however,tae Wilding or improvement is sold within one year ofoompletion.the owner-
Wilder will love the Wrden of proving that W did not Wild or improve for purpose of
sakJ.
0 1,as owner of the progeny,am exclusively contracting with licensed convectors to
construct the project(Sec.](MA,Business and Professions Cork:)The Contractor's Li.
cams law does not apply in an owner of property who ti or improves themo t.and
who contracts fur such projecu with a convxmr(s)licensed pursuant to the Contractor's
Lie se Law.
lamcacmptunder Scc. ,B&PC for this ream
t
owner _s (-e Dae//--7:2= t�
TSVORKERS COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
1 love and will maintain a Certificate of Consent o self-insure for Worker's Condition-
.firm as provided for by Section 37M of the IaW,Cora.for the performance of the
work for which this Permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
370)of the labor Coke,for Ne performance of the work for which this Permit is issued.
My Workers Compensation Insurance easier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mks Beth neednotWcomPletedifthepermitisforomhundreddollars(Slf)I
micas)
I cenify that in the performance of the work for which this permit is issued.l shall it,
employ any petssrrnap;py manner so as to become si nmtbe Wnrkcrs'Compcnsauun
Iawsof alit dyl
Is I
N I E TO APPLICANT:If.after making this Cenificatc of Exemption.you should
Wcomc subject m the Worker's Compensation Provisions of the IaWr Coke,you must
O O forthwith comply with such provisions or this Permit shall W deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
F I hereby affirm that there is a cnnsWnion lending agency for the Performance of
Cithe work for which this permit is issued(Sec.3199,Co.C.)
(y Q Lender's Name
7 z Lcnder's Address
)Q 1 cenify Nm
al I have ad this application and stag in ththe above ots relationis
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correct..I agree comply with all city and county ordinances and sue laws relating to
0 U
U aWyc mentioned construction, hereby of this city to enter upon the
r W above mentioned to..rofictry for inspection keep hs.
Fa a (We)agree m cave.indemnify end keep harmless the Cay of Cupertino against
h inconses.quent of(hecnmsan of
hisses permitamay in any way acrneagainm said City O_0
U z A consequence of RSTAN S A permit Issued by: Dale
lir APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS.
''��� 1 Re-roofs
slfanawre or ApphcaI IAZAvactw m
IIAIARDOUS MATERIALS DISCLOSURE Type of Roof
Will taeapplicantor future Miam hl.)Cge,Chaptstoreur handle Health material
az defined by led Cupertino Municipal Code,Chapter 9.13,and the Health antl Safety
,doLCode.Sc�YLs 25533(x)9 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant wee If a roof is installed without first obtainingan inspection, I agree to remove
emil harandous air contaminants as def d b tic Ba Area equipment or devices which p g
Di via 9 r r Quality Management all new materials for inspection.
Oyes g7„
In real de haraknusmakrials reyuirelnenu underCloper69Suf Ne Califnr-
nialkalth&SketyOkc.Seeunro 355115,2551)alk 3553a.1uedrrslaklha iftW Wilding
docs ton currently haw a tenant that it is my ropinsihility to redly be occupant of the
requirements which must W mel Prior to issuance of a Certificate of ppmey. Signature of Applicant Date
nr authumW agent D,e All roof coverings to be Class"B" or better