00100204 (2) CITY OF CUPERTINO, '
BITHPIvGDtvtslory "4PERMIT - CONTRACTORINFORMATION 'r
BUILDING iM;DRFSS. - - 'f - - PERMITNO. ,
BUDGET PLUMBING ' ' *001,00x04.,', ... .
OWNER'S NAME: , APPLICATION SUB DATP.
rpp�.npy i ANT) SUE AN M 28695. ROANOKE 'ST: ,. r : 10/31./2000. ',
+HONE: a " ' SANITARY NO. ' `CONTROL NO
(510)303-7847
a0 O ARCHITECTIENGINEER: ., BUILDING PERMIT INFO
•'z u❑ 'a Bli ELECT', PLUMB MECH
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Ozz Ei n Ih by affirm
front
pr DECLARATION ovisions of Cha� 9lc n S r r� •Job I)eSCrlptl0n
Ft+Ein widScl 7000) fD .,n3ofthe Olinersand Profession,fend no,Farm
_ • - -
i:ml f,°cm„ d f`` t Lie x - WATER." HEATER- REPLACEMENT °
x 0 d F Date - Contractor 1
00'3 a m ARCHHECT S DECLARATION
Iunderstand my plot::hall be inset spablic records
00 Licensed
OWNER-BUILDER DECLARATION ° . - ,
+�+= I hereby affiror that I am exempt marn the Contractor's License Law for the
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follonvir,event.,Needime70319 Businessland Proodficrjoll,C e A y cityelement,
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which requires a permit t t ft p demolish, repair nys con
tay3$ prt t , alrequiresth p11. ut for archpermit t(,file a signedatement 2 thin he licensed musurele nufficpnwd,imim Contho Liceno,Law Chapter 9 Sq. Ft. FloorArea ' , Valuation
(ca g will,Section 7000) f D" 3 1 tM1 B : J I reo ,Cole) - - .
or thin h maul rn d theM t tire p, Any inlet on - - $GOO * .
ofSection 7031.5byany ,di. Ifor apermit -bleats the apple and In acv'I pe rot, _
iduchrumne than Bel,hasuoideflarrS500) - "APN Number ;Ocdupaocy Type,
_ El as owner of property,or m)enplay 'md ill d the g :In ' s1 compensation 11 '-'x '=,171 ' �It�l.
wI f t r I n, d 1 ff d f I (Set.7,000
Holmes,call Precision,Code The Cotrurneder,Ll,coa Lia,ames no,apply to or, r - RequiredInspectionsowner fp pry Wit(,builds p 1 d h 1 "h kl If
ti
nr through .a we emplye p. adtht n- p I t-' I d l r . . _, 524 , — ' FINAL PLUMBING. ENERRY" ..
offered for sale If,ho euq Wv holding impn ve nem , ole with n to year of
nom ltaom,theownerhnllder will have Ilelander,L vin,than haaid indb ildeTEST
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p n s -' 505 :--, GAS ,
improve rnr pour",ge5,r xale.>. �, - r ," ,
11. '907 ,FINAL PLUMBING , , - -
°I ffile Formerly, exI 11y xintolefir,withI cd nl Itoto -
c,n I I th project(S 70,14,Bmince,and P f :C de)Tb C trues
License Law does I I ply loan f property 9 b de improves thereon, { .
and who contractsfor such projects with onoaalof(,) lacenaed purrunt to the'
Comacr,Li ci
exorders a ,BG PCto,(Ill.rca.on �0 "
LLL -
Owner J
WORKER'S COMPENSFNSA910N DECLARATION
ARAr10N
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Ihereby afire under,nllY ofp11 one I ofd following I W t
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1 have and will ansionatin a Cori I cam of Consent In,elf ro re for Weakmc
Contlwnsation, as provided for by.Secdon 3703 of the Labor Code,-.for tee v
•parfommncc of the work forwhich thi£pemtit is issued. ^ 4- or
have and will aNialun W...ver':Chiral....i ,,source i s red by on
3700 of he lab Cd the t (of the work fur which the period
is or. y-••
Issue) My Workers Combination,houra and Policy number one: -
Carriar; Policy Na.:
a, CERA IFICATION OF EXEMPTION FROM WORKERS'
.COMPENSATION INSURANCE '
(This section ri not he completed if the permit is for one hundrenl dollars x
(Sl our
I comfy that in the peffrounare of the work for which thisp iii,issued,1 - - t
-shall not employ,any person in anymaniter vo m in become subject to the Workers"
- C,mpennlon Laws ofCalifornia.Dwn
NOTICE TOAPPI-CAN,11 after ammir,this Certificate f Ex d . should' t -
become subject„IeW kr Compensation provisimu,at the L� 1 C yuntis, .a
Q O fortilvllt comply wall such provisions or this pint&bar beJ drevoked e , _ s
'F 4W CONSTRUCTION I[NII ING AGENCY -
' I h short door th is t i l e g agency for the perfo els tm of the- k f which this permI',.aoeJ(See.311 D.Civ:C-)
Q Lentis Nane -
r7• z Lender's Address
V - 1, If o tin , d,h''application d.,a, thath h f f ' .' n ` A
WFyoure,riy oil anind,,ill,all rt)roof munly milinumv,andtmlaw, 1'fg -
C„J to building anno Own d bece,small ,m,raodim,lorldris city to emei-in, o -
} (s] the ub t' red popery for ispecti, Proposes.
t t h r
F W (W)agree t indemnify andkeep h I..the City of Cuporlintrajoinse
V]
liabifities,judgments, ts and expenses h h may in any way recruit against said
V City in counc,amillsoof(he bra nine of this pcould - , r +
APPLICANT UNDERSTANDSANDWILL COMPLYWITHAL[;NON.POMT - -
SOURCEREGULATIONS - Issued Date '
Signnhrre of ApplicvnVGovactnr Date: 'Re-roofs' - - • Y '. ..
HAZARDOUS MATLNIALS DISCLOSURI - • ”
will derallfem,tollatione b ld goo p,r,,,arvu,naval h :b a,dnai-. Type of Roof' .. . .
C darned by 1pan to net n'e pal epee,Chap,er912 end the Hcnllh tail Safary
Calc,Section 2553 25532(u)!7 D No
All roofs shall be inspected.prior to any'roofing material being installed:
wild m api l e, r f t building' occ,pamt use equip t devices whavh If d roof is installed without first obtaining an inspection, I agree to remove
Vot hazardon,air contaminants as definul by the Bey Area Air Qt nifty MaragemerI -
dool) - all new materials for inspection. Applicant understands and ,will comply with
°YeN °"a '
-all non-point solirc_e regulations.
1 have end the hazardous uric ial l Hants under,Chapter 6 f,of the ' -
r
California &
Health of Sections 2550525533 und25534I m
d . ry
dtht' ',v
- f the building I t currently have tenant,had t': Y -po:bil'ty, fY the, _ r
ccup lof,he terminations hich nus,be mel Prior to issuance of v Cenfcme of �•
I. Occupancy. •, -
d Signature of Applicant Date,.; '
Ov - n-nred!agent Da,e• L :All roof coverings to be Class"B"aor better^ f
OFFICE