02060017 (2)V,: oFFlce
'CITY OF CUPERTINO
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BUILnING'DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDINGADDRESS:
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PERMITNO.
19752 BIXBY DR
NELSON PLUMBING
02060017
OWNER'S NAME:
APPLICATION SUB DATE
.SCOTT
RYDER
1533 ALTA GLEN #1
06/04/2002
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PHONE:
SANITARY NO. CONTROL NO.
(408)280-5311
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ARCHITECT(ENGINEER:
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BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
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„ r r - :LICENSED COMRACTOR'S DECLARATION 1 " -
:. Job Description
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thaipby,ySy�rm Nmlam li<eme and provislom"e of Cha lag .romancing
twin SeRtoc., y,.)Of tltvlii n'3Bnfie Buan o Pmmm dmylieense
is foil an
License C/100
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/ ARCHTfECT' ECLARATION
RE—PIPE/WATER SERVICES-'
Med � lens rthall he s public nee
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OWNER -BUILDER DECLARATION
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1 hereby .lien nl l 1. exempt from the C License Low the
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(Section suions Co
Business and Professions Code: Any city or county'
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following «aeon.ermitt7
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permit construct, demof...Vany SW[Ntt
which «gal«san,
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ca thepplimmprn.. It
. prior m its issuance. also «quires me ePPlicanl felt wch permit to Ele n signed amcmenl
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that ho is lirsdsed purapanf to the provisions of the Contractors License Lew (Chapter 9
(comnieritin8 with; Salion:]000I .(Division 3 of me Business end �rofeuions Code)
-V1 Valuation
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: ' i `., 3'.6' 0. �'j-,, = �i ? i �,i''' '
or Thai fie i{ a%empt meiefioln end the basis for the allegea uJumptron. Any violation
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-of SecoanI1.5 by any applican1 for o Permit subjects the applicant to a civil penalty,
mf not more then five hundred dollars(5300).
Occupancy Type
APN�TffFLOOR
202 PL MBII`]'G'f'
° 1, as m anermf Ne property, or my employees with wages as their sole compensation.
will do the work, and-theatmclure' is nor intendedoroffered for'mt. tSa'7W,6
' Bbamtis'tmd''Professions Code: The Contractor's License Law does not apply m an
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502 - FINAL PLn:nryPi4 (!Ps by
owner of property Who Wilds or improves thereon, and who does such work himself
,or through his own employees. Provided that such improvements art not intended our
507__.-FINAL
.offered sale: If; hdwNldethe budding of Improvement ement n sold within ane year of
_..PLUMBING _.._._._—_..___ --------
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muiTor
'completion, the owner -builder will have the burden of proving That he did not build or
improve for purpose of sale.).
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CJ 1; os owmr of the progeny, em exclusively contracting with licensed convectors to
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onsimct the project fSec. ]044. Business end rofessions CodeO The Contractor's
Licen I:aas does nw apply t owner of pr rty who builds w improves thereon;
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cast Yoq sac .WnI I with a e.rannt imovalmts) licensed puuto the
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Ca In 11.... Law _
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CO E GN DECIIpRAT10N
I hereby, all u der penalty of peijury one of the following datimations: -
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01 have tind will mauntain'e Cenificate of Consent to self -insure for Worker's
s.per
Comps i provided for by Section 3]00 of theLaborCod for the
of Ill 'w rti for this!. nn 1 s e
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° 1 have and will m i n Worker Compensation a es regwrtdP
or er
3]00 of theLabor Code for the performance of the work f which thispermh Is
e a work Permit is
Isms My WorkeYe Compc i In ante a carri r mJ Pob y mbar ere
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Cade rt I (i'<311It Cr w'•.pohcyN ✓:.
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;1-f, CERTIFICATION OF EXEMPTION OM WORR-`FR aRS
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COMPENSATION INSURANCE •N `1
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'Mix iiatumneed tint be eoinpleied if the permit is for one hundred dollars
(EIW) or less.) ••
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y pe f w k for wN m permli is issued 1
fh 11 1 empl y, an person I a no con object m Ne Workers
Co. emit; n I,aw of C I'f p em .' `
[JgttICE TOA ef(n C rt .....i
Icv m tion should
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c tib en he oris o I e. you must
forth wuh comp' wuh such pmvlslnn or is all ed revoked.
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:CONSTRUCTION LEN LNGAOE ''
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- l h by affirm that there Is a construct dm gene, for the perform
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QLender
of the err which NS Itsusnd5 709]ggvC
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ladders Addttul - •+ -
y It liify thea l hove a lhb ap,i a ton and stale that the' above information is
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enrten 1 agree sg4o ply {h -all 'ly and county ordinances and Inte laws relating
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Int Wilding confrnclton, d area .Ih }ettp«ScnlnliVes of lhlS Cily le enl[r upon
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the above-Im a tared o rt f I pec oa puryoses. .
'(We)d reel".IN I a 'C pn cep harmless the Ciiy of Cupenioo against
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liabilities.lodgment c I. nd i n h«hmay in any way u<cfue egpinn said
Cry seq tic of gmdu (I Penn 1: -
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tpPt ANT D RS \YDS. P t COMPLY WI AI , UN -PO
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Issued by: Date
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Re -roofs
D TERIALS DISCL U
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lt<'ll th appll r fuws bW IJfng we p 1 sf r h an 1; haairdoutmte al
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Type Of.Roof .. •- _.. •..•r.
Cadet en me C. realm as Safety
y pe 90 Mu 'pal Cod Chapter 9 12 d the
Cod Saeon 2311_(at
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All roofs shall be inspected nor,io,an roofin material,being installed.__..
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wont ppp 1 rfuturebwldotgxcupe 1 se equipmentn-devices'which
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If a roof is installed'without first obtaining an inspection; I'agree'to remove
emit Wouldown ur conaminams sidelined by the BayAumAirQmfiry Management
Dsl et
understands and will comply with
Applicant un
"^easements
Fall" non -point source reglattons: 1 `I .. i . _ _
1 have mad me o al tats tsunderChopter 6.93 of me
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Caldomis Health&gee ty 5 ti s 305. 235)3 and 23334.1 undemm�d shat
I t e biding does not u a en ,Ihatit if my respensibllhymnrnify the
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.,cap he issua ce of a In am. of
of the qui a ich u t met ""m
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Signature of Applicant Date
own a Da ..
All roof coverings to be Class "B" or better'. „
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