01100147 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10415 N BLANEY AV DIJOSEPHS PLUMBING 01100147
' OWNER'S NAME: APPLIC TION 5 B DATE
CALDWELL RODNEY C 205 WYANDOTTE DR 10,29/2001
PHONE: (408) 365-2058 SANITARY NO. CONTROL NO.
OO
VARCHITEC iENGINEER: BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
ai I"U O CJ
S LICENSED CONTRACTOR'S DECLARATION
✓ 1 hereby form that I am licensed under provisions of Chapter (commencing Job Description
)N-G Ye provii P 8
tw witnsee0op7Boo)or°mismn3nnheenamesaanarroasainnacpae,anamrhanse REPIPE.
kms-' in^re rat dna erce ��
z z< Clas.s Cm a
LLLLN rSmG�— SDEC1Or ����
O Q la CHITEe use DECLARAscom
- J 1 understand my plans shall be used as public records O�
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c,p,aon
.LiC[nProfessional
�
O ivOI BUILDER DECLARATION
1 hereby aBrtnthr,1n.exempt from the Comm License Law orthe
followingreason.(Section 7031. Business ands Code.Any city or county 0
L�
_800
which quirespermit t construct,eller.tmpronve,demolish p any swcturt 5UILDIN
pt
at d3l' n. d purlinualpi
._..... _ _ _
theorrivisions ofthe Contractors License La (Chapter9 ` �` -tea
(commencing with Sect ,7000)or Division 3 of the appt ness and gr( ions Code) aa�aV 13. 9'?I3,1FJQ4r;bto, 1iy S'y'Ta�;. Valuation
or Nal he R exem i therefrom and the basis for the all2-ed ei&c trod.An j•"'➢ '
p g p y violas on I
-'of Swim]031'.5 by any applicant for a permit subjects the applicant o a civil Penalty
iof not mom than rive hundred dollars($500). 2024PNNN*92FL00R PLMBI'NG Occupancy Type
01.as owner of the property,or my employees with wages in their sole compensation, - 301 - ROUGH PLUMBIN
-wufdo the work,and the-swemm is not memded or offered for sale(Sec.'7641, 5 0 2 - FINAL P]Iddt)1)�' p f�jnn ,
'Businad
esa'and'Professions Ce:The Cnmmaor's License Law does not apply to an J&`TnS {fsGY''
owner of progeny who Wilds or improved thereon.and who docs such work himself 507 - FINAL PLUMBING
_or WoWgh his own employees.provided that such improvements art not intended or -
,offered fur side:if however,the Wilding or improvement is sold within one Year of -- ---- - ' " '--"' -'- '— '„t• - -- - -
cdmpletion,the owner-builder will have the burden of proving that he did not build or
improve for purpose -
❑L as owner of the property,7 an Business a comroning with de:)Th contractors to
Contractor's ""-"-
>_ <' conswn the projml(Sec.ZOaan owner o,and Professions Code)The veshern,
and who
Law docs nm apply man owner of property who build or e improves thereon,
Co who comruda for with.a commnor(s7 licensed.pursuanttorbc
_ such projms p n
Convacmrs Li<rnulaw. - ..
.. .
❑lamexempt under Sm:'„ ..til " .,,B&PCfar this•m son
_ Own
Data
r WORKER'S COMPENSATION DECLARATION -
" I hereby affirm under penally of perjury one of the following declarations:
❑ 1 have,antl will'maiotain la'Cenificae of Consent to self-insure for Worker's
t, Compensation, in provided for by Section 3]00 of the Labor Code, for the
'performance of the work for which this peroin is issued„„
❑I have and will'md nt Work Compo uo 1 :rauc,ro my abed by S«tion '
3]00 of the r Code,for the,performance of the work for'which this permit is
issued. dersC mpeniato 'Ins eolith! d Pol y mbe t
[�]��,„, te�aa,�// ff ( �-^^ /J✓���1 �p _, ., _.._�..._-c... -.. .._.. . . ...,. __
vn4l?fc olcy No.. 7 r'F .Sh 3 ! ii
r H ERTIblCAT10N OF" ION FRAM WORKE ' {.�N: i
need not W mmINSURANCE ti
_,.j .. COMPENSATION t ..-.. . -..._..__._....._�_t. ._ - _..._..__.
section Pleed d the permit is for one hundred dollars
1S 100) less) f
., I MfY thl nth of 'flh' ktf hhth'pemit .. .... ......... . ... .-. 3 .. ,.... .. �,
ih50Person
I employ any Pe son n any manner so as m become sub3cct to the Workers •• ` y ••
Compensation Laws of Califomie:Date `
Applicant ., , . ;.. .,. .. ..
`NOTICE TO
APPLICANT ,ither makingthCertificate o
nf t rexyou should
z Aceto,subject 16 the Wrilm's Compensation provisions of the Labor Codeyuu morn
forthwith ply with such provisions or this permishall W chimed revoked.Z 0 -
COIONLENDINGAiGnENCYC
> sIh byrcthtrh c sac 't i lendg agey! thepc8rm e - - -- - -
I. `
y ,.a of the work for which thispermit's issued(Sec 309] Civ.C)
=0 Lenddrs Name. .0 ...,.
Irndera Add •
I en fy&I I have mail this application ntl state that the bo -informationis
conect I agree to comply will,all city and county ordinances andate laws relating
0 V to buId ng c xmurmi larrod hereby imhb ate prose tatives of this city or enmr upon
rW the above- cmioned property for i nspection� purposes.Al. (Wc)iime to save,indemnify sadkeep harmless the Cit y'of Clpeninoegainst
Vi liabilities,judgments,casts and expenses which,may in any way,accrue agairm said
.V"Z City co s quence of Ne'g t ng of Ni pe t , ""
APPLICANT UN RSTANDS- I WI LCOMPLY. ' ALL NON.POINT''''
so 11;110 p'� Issued by: 12 Date
'gnat,rear. 'rnnds omractor ^, . .. Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
asd f e' wjlb het C ea t f rare Wilding g occ p t mm 6 handle Harare'li mr .ate l Type of Roof
y pen Municipal Cod Chaps 9.12.and the Health and Saf tY C - a { - - -
Cdde S❑ecY n25532fa) r IION ,, \ to . flTIr''t i I',"C i?:r,,,, ; Z 4 1 art'! k$ w 5 C int:j�l.
'' _ All roofs shall be inspected p�or.[o.any-roofing material being.ins[alled.
,
• twotoapplicant fuwre Wilding'oac pa Luseequp t a iceswnch If a roof is insiallediwithout first obtaining an'inspection;I agree'to remove
emit hazard t is as d fined by theB y Arrn'A Quality M agement
- all new materials for inspection. Applicant,understands and will comply with
❑r o N „{ all non point source regulations. -
I,h Sd.the haaardous materials rtqu mcnrs under Chaps 695,6(the
California Health&Safety Cod,Swino s 25505,25533 end 255341 understand that
iffheWild.ungdonspolcu a tlyh union,
athat t my responsibilityt otify the-
occu t yf th qui im!p as !!!h c moa be met p to issuanceof a C rt fmum of -
tor
.r Signature of Applicant Date
woe 'touthorizeaagent ' pot . All roof coverings to be Class"B" or,bet[ef
I .' {. OFFICE-.