02050081 (2) CITY
BUILDING DIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
8201109 RCPERMIT No
HAVOYA DR DIJOSEPHS PLUMBING 02050081
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� � I PHYLLIS L 205 WYANDOTTE DR AUµ TiolasjlgVff2
' PHONE: (408) 365-2058 SANITARY NO. CONTROL NO.
O s z ARCHITECHENGINEER: BUILDING PERMIT INFO
aBLDG ELECT PLUMB MECH
S m i LICENSED CONTRACTORS DECLARATION Job Description
jz_to Ihereby affirmthat lamlice meaidepro.....nsofChapter9(commencing COPPER RE-PIPE
mC with Socio 7")of D1vismn3ofthe Busesand Pmfesslor'CWe.andmy license
fyE-! is inf11f Ke and IT •. /
O i v cLic I
ECT'S DEC /
LL
LL 1- ARCHITVtATI N
nY O; 1 m dcrsmnd my plans shall be used as nbc records
3 d O ceLiccnecJ Pmfcai.nal
' o hOWNER. R DECLARATION
1 heresy.(firm that I am exempt exempt from she Contractor'sLicense Law for she
!-z< fallowing reason.(Section]031.5,Business and ProfessionsnsCCode:Any oily or county $5800
Pin
which requires a pennot to construct,alter,improve,demolish,or repair any stricture
a3a Prim a it, -Iws mulattostn mlicam for such Permit to file signed watemem
that In.is I.eemed ,1 lF{ I -
psu p .onsof,hftheBunorsandPeLaw(Chap¢r9 3b�.�3.ff ODE-.®d9a r' Valuation
Iron ng 'tit sun mean the b ai°n 3 ohne lejod ma and ion.Ancona Bode) (....� .....'...�-... • �„•.
or Se be is 31.5 b aa,ap m'anJ the basis for objects
alleged applicant
b.Any violation
-of Section]03 LS by any applicant!m a permit avbjttb,he applicam m e civil prnalay
of am more man Five trimmed dollars(S500). 202APN lis6A7L 0Bd2 FLOOR PL BINGc. Occupancy Type
Ol.aa°wneroftheproperly,ormyemployeeswithwagesastheirsolecomparrovion, 301 - ROUGH PLUMBIN
w11I d°,an Pro and me structure C nt intended Li enseLaw for sale(sec:to an --502 - FINAL PI���S�s T GYs;'t-;
'will d a'he Professions Code:The is Contractor's intens ed or offered taw does ale apply man
awne
r of propcny Who builds or improves thereof.and who does such work himself 507 - FINAL PL B I NG
or through his own employee:,provided that such erner an no,intendedor
.offered for1 If M1 ever she Ibuilding-orv
p cmc ,is sold 1M1 n one year of -'- - "' '-'"' ' ' '"'--'- - - - -
mpt a.budder w01 have theburdenprovingofthat hea abu Id or
improve -
mf pryox ofsl l
Ser.
P 3o an of proPeroY _ __ __._ ._. .._.
❑In I cmtmcI,_rlS c! ' tg thlc d Iranoram
con wet the a S c ]6l4 B Codc:)ThContractor s
I s n<doesnot
n an d h b 'Id p thereon,
Cum t License s 1 d P (crags)1 used p m to the . .. ._ _.
P Pe Y O
project 1
and h cora act f ch ro c n with ,ac
.B&PCT phis mason s . '4':
)wi re t �Draft'. .
t WORKER S COMPENSATION DECLARATION
1 b,reh,affirm under penalty o(perjury one of the following declamlions:
C 1 have and will m.imein a Cby Se ti of 37W o m sdf-insure for Worker's
Compensation, m provided for by Section 3]00 of she Labor Codc; for ,he
- perf.onantt of she work for which aM1is permit is issued..
111 h d ll maini.in Wok Coirmperosafcm homaicsquired by Section
J]00 of,h lobo Cod f ,M1 perform cp fah k f h h ah' pcm,i, s ,
rw�
ssu d M W keyr Compe ,on/In,mscde "d Pol cy be areY 9 ry/
'r s !CF,RTIPICATION OF E%EMPTION FROM WORKERS+` -' � ��j r,
"` IThii union,iced not tic completed if the permit is for one hundred dollars " - _ f I::::'3;1:;•3
($10)n or less.)
t
hal i 1 employythat n the Performanceof M k f r which u Permit s issued.1
shall - ,crap)y any pe any marine, os m b[Come bject to the Workers '
Compenxl on Caws of Celimmm:Daae' -
Aigliciiial''
NOTICE TO kglM1SCenfm (Exempt you
z nccomc subjecstotncN ke C npcosatonpo onsofth Labo CW y' mus
Q fonnw th omply'with such p isions or this p it ehall be d d .ked.
z _ __...._ _ .. _.... I ._....
"CON Sem iss 6ON'LENDING AGENCY
which
this pe n co.t 1lending agency f the perfo.. ,I
i.a
of Lender's
work f. h'ch thispermit "slued(S 309] Civ.C) "
y.p ' Lend N ...,, . . .:.v. 1... . . ....-,.. .__.... . . _ _......___. _ .._.... . . .._. _.... ..__
Leede Add av,
D'Z
V' 1 ccs fy Ihm l he «ed this applicaY d stn¢that�h b x information is '
IL,N Carred.1 agree to comply with all city and county,ordinances and state laws relating
' 0o[) to building c°nswerom.aoil hemb'aulhotlaerepresemmive:ofthis ciaymemerupon
. pa_4TW the above-mentioned pmpeny for inspection purposes.
�dIY (Wc)agree id seve,indemnify and kap harmless the City of Cupertino against
liabilities,judgments,costs and e"nxa which.mayin any way azcme against said
City in conxquence of the granting of this penitis.,'
APPLICANT t'NDER$T Ts'NO W'ICLCOMPLYF'fTH'wLE NON-POhNT I
c "RE Ennarl-'• S^� Issued by: Date
ignawrc°f ppotan-onuacmf ',; •` ,Date - RC-TOOT$ /
.HAZARDOUS MA RIALS DISCLOSURE
Will the.pplcant or Name WId' gocc p tsm,e or hadde hitArdam,mmem, - Type.Of ,ROOF .
as defined by theCupertino M n c pal Code Ch pm 9 12 d the Health and Safety s .- -= - " '---- - -Code -
Section 255321 ) s It
0I' 4 ' _All roofs shall be Inspected poor to any-roofing_ma[eria] being installed.
N non app) m far..bug he t eq p tli a witch If a roof is installed without first obtaining an inspection I agree�to remove
comn haza d it<onmm a s defined b)N B y ArtaA Quality ev...lament g
District? all new materials for inspection Applicant understands and will comply with
1 Cl Ye
l all non-point source regulations'
I havetrwd the h and 95 ' 'lpe . ote "a
Calif ora Health&Safety Code;Sections 25505;25533 and 25534.1 understand that
iffe,haildingJ°c1 A'i'n tlYnt °1,fY�e . . ..S� .... _ . ._ .._.... .---... ... ...
yresponsibility- to
cmip tofahc'q mnt��mus)b map t i.sb f Cnficam of
1. 0 �' a cy
gna[ure of Applicant
roof coverings [o be Class Date
An
m agp a D, g s"B" or better
i_ �
OFFICE----