02110088 (2) CITY OF CUPERTINO "I"m4k, QQ.
BUILDING DIVISION PERMIT CONT RAC=TOR INFORMATION „i
Bu QA 0Es2ANYON OAK RD. K. S . PLUMBING PERMITNO2110088
oWIFdOWARD SILVER 3047 VAN SANSUL AVE #1 BP
APPLICATIT"iSpT�tI 2002
ah
orZONE: 408 551-0707 SANITARY NO.( CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
CJ O O O
IOROo LICENSED CONTRACTOR'S DECLARATION
<U U I hereby affirm that 1 am licensed under pmvi Ions of Chapter 9(mmmcncing GAS LINE Job Description
fn<i with Scclinp]IyXq of Divisinn 3ofNe Business a�ficAons Code.and my license is
in full fxrwe w effect.
~i2= License Class Lic.M
�a
ARCHITECTS
DECITRATION
�yy< IunJersmnJ my plans shall he used as public records
6w
/ ILlyllsi
KOLS
FLLwO1 Licensed Pnlldssinnal
S OWNERBUILDERD[CLARATION NOV 1 4 2002
a a Z affirm I hereby arm Thal 1 am exempt from the Contractor's License Law lu othe $2000
w OO following twson,(Section 7031.5.Business and Professions Code:Any city or county
e w$ which requires a Permit to construct,alter,improve,demolish.or repair any structure
FZy prior to its issuance,also requires the applicant busuch permit m file a signed statement
<
that he is licensed pursuant to the provisions of the ConicieLor's License Law chadder 9 3Wrd0M&2A0U1LU1NfL i Valuation
al-0 (commencing with Section 7000)of Division of the Business and Professions Code)or
i R S that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a phimit subjects the applicant o a civil penalty of
not mom than rvehandrcddollars(s5W). 202PNN UNDERFLOOR P UMBING Occupancy Type
❑ I,0 owner ofthc progeny,or my employees with wages as their sale eumpenastion.
will do Ne work,and Ne smucwu is not intended reoffered farsale(Sec.70I .Busineu
1k}r
and Professions Code:The Control License Law does not apply m an owner of 302 - TUB Sc q J CtIODS
Property who builds or improves thereon.and who does such work himself or through his
own employees.provided that such improvements are not intended or offered for sale.If. 502 - FINAL PLUMBING ENERGY
however,the building or improvement is sold within one year of completion.thc owner. S06 - GAS TEST
builder will have the burden of proving that he did not Wild or improve for purpose of
.1c) 507 - FINAL PLUMBING
❑I,as owner of the property.am exclusively contracting with licensed commissions to
construct the project(Sea Bebt,Business and Proclaione Cale:)The Contractor's Li-
u taw does not apply to an owner of property who buil&or improves thereon,and
who ntracts for such projects with acomracmr(s)licensed pursuant mNe Contractur's
se Law.
am exempt under
�S�ecra ,B&PCG thi talon
Ow yis_
Da
�r OZ
WORKER'S COTIPENSATION DEC VtA,
I hereby alBsm under penalty of perjury one of Ne fo ow mg declarations:
❑ I have and will maintain aCasificate of Consem toself-Insumfor Warker's Compem
cation,as provided for by Section 37M of the Labor Code,for the peRrmtance of the
work for which Nis permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
370()of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance easier and Policy number am:
Cartier Policy it
CERTIFICATE OF EXEM PILON FROM WORKERS'
COMPENSATION INSURANCE
(This union need not becompleted lithe pi is fnr one handfed dollars(51(K)
to less)
1 comfy that in the perfimnanee of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL,after making this Ccni livate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
O z forthwith comply with such provisions or this permit shall he devoted revoked.
z O CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that there is a construction lending agency for the perlimmanec oL
Eli the work fur which this permit is issued(Sec.3(X17.Civ.C.)
G.10 Lenders Name
d
z Lender's Address
o
U O 1 ecnee that 1 have mad this City
and court and stale that the shove information mining
is
0Ubonding lurooand withall cityand countyordinancesof and Stam lawsrelininge /Y ,
O V bwWingconstruction,lioneosey hemby inspection purposes. of this city to enter upon the
FW ahovo(we)are progeny for impaction purposes.
y (We)agmets,cove,indemnifyandcharmless the City of Cupertino against
h nconsegranting may in any way eccmc against Ci
in
qunce of the ierves h
granting of this csPermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL OPOINf Issued by: Date ' Civ/
SOURC R ULATIONS.
/r i'3'Oz Re-roofs
naw o ppfcanl/Cornacnor oat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or future building we.fo nl swrc nr handle hazardous material
as defined by the Cupenim Municipy GNL Chaptar 9.11,and the Health and Safety
Code. [Dyes 25572(x)'! �-ryJ All roofs shall be inspected prior to an roofing material beim
[D yes P P Y g g installed.
Will mea lletm or fmurc bu' quip If a roof is installed without first obtaining an inspection,I agree to remove
Pp mg rccupam tau c mem ser devices whish $ p g
emit hn,ochn,air e.nourn an6 as Tined by the Bay Arca An Quality Management all new materials for inspection.
District?
❑'es
I have read the for anlous mmefialsrdyuiremenu under Chapter695 of the Califor-
ma Healm&Safety Godo,Sections 25515.25533 and 25534.1 und,,.d Nat ifthe building
dna not ent mndy hast a wnan,.thin it is my resioreihilay to notify the aeupant of on
reyui menu whish muv / Iprionni mancenf.Cenifc I sup ey. Signature of Applicant Date
S �' 0
o ramolco<dagcnl Dale All roof coverings to be Class "B" or better