01010039 (2) ' CITY OF CUPERTINO 1. '
ROLDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
7642 F DERWOOD CT BUDGET PLUMBING 01010039
OWNER'S NAME: APPLICATION SUB DATE
a'T28695 ROANOKE ST 01/09/2001.
of{ONE: SANITARY NO. CONTROL NO.
(910)303-7847
�ii O O ARCHI'fECT/ENGINEER: BUILDING PERMIT INTO
w BLDG ELECT PLUMB MECH
u�
Z S H LICENSED CONTRACTOR'S DECLARATION Job Description
O z—e 1 herehy affirm that 1 am licensed under prosisions of Chapter 9(commencing
Mad with Section700B.f Diskanlofnhe Rusines.and Pfofcssi...Cde,and.yliceme
s in full force and effect.
�W I a Licensecmxs ue.0 WATER HEATER REPLACEMENT
°' a U Date - Corma,or
ARCH]I'ECT'S DECLARAMON
I understand my plans shall M used as public records
?,p Licensed Professional
OWNER-BUILDER DECLARATION
se I herehy aflina that I am exempt fin.the Comment',License law rot the
5?a following ri(Section 7031.5.Ruxinas and Professions Codi:Any city or county
CC F p which requires it permit to contract,alter,improve,demolish,or repair tiny structure
C3$
PImur it assu:mce.also requires the applicant lot such Permit o file asigned sumrnem
d,athet.hr..ed mrstual m the pmaixtm,x Of Contractors license Law(chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section TIDO)alDivision 3 of the Business and Paressions CWc)
or that he is exempt merchant and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applisma Porn permit subjects the uPPI cm,la a civil penalty
of not mom than five hundred dollars($500). - APN Number Occupancy Type
❑1,as owner oohe property,or my employees with wages as their sole compensation.
will do the work,and the stucwre is not intended or offered for sale(Sec.]OW, 359290273 010
au.th rs and I ode,slans CWc:'1'h.Cnnwmor's License Law des am ai 1.rot Required Inspections
owner of propery Who builds m imp sots demon,and who does such work himself
or through his own employees.ptmmed fed nth improvements art not intended or 502 — FINAL PLUMBING ENERGY
o0'ered for sale.If,however,the building or improvement is sold within one year of
completion,the owic-lumWef will have the burden of proving that he did or hoild or 506 — GAS TEST
improve for purpose Aside),
❑I,asonernfthepeny.amexclusivelycantniwithlicensedrnmruclorsIt 507 — FINAL PLUMBING
wmp
conswn the Pr.jco(Sec.TW.Business and Professions Code)rue Connector's
License Law does not apply to an owner of Prepeny who hailds or improves t
and who vomnmnts fill such projects with a rnnnucn,na) Ven rrd pomata ,Wife
contractors License lye.
13Iver exempt under Sec .B&PCfnrI rreaxnn- _17� -
Owner Dare -
WORKER'S COMPENSATION DECLARATION
I hereM1y affirm under,penally of perjury Dire of the following de
love,and will nulinmin a Cerificme of Consent to mlf-inmm far Wnrkct
.o.peasation. d, provided for by Section 3700 of the Lesor Cale, lin the
performance of the work for which this permit is issued.
❑I have he will ttwlnte, Worker's Camance if] eworkf u%required by orrit tis
PrP of the Labor CWc,for the Performance Carrier
the work for which this permit is
issued.MY Workers C.mpenxminn Insnrnnce currier and Policy number are /
Carrier: Policy Na:
CLRTIFICATION Olt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut W completed if the pmdt is for one hundred dollars
($RP)or Icss.)
1 cenify that in the performance of the work for which this permit is stand,I
shall not employ any person Lt any mmmer sen ns In hero.,.object to be Workers' -
Compensation Laws of Califomie.Dam
Applicant
NOTIC13 TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject to the Workers Compensation provisions of the Labor Code.you must
O forthwith cranny with such provisions Or this permit shall hedeemcd mvoked,
r
.�i
CONSTRUCTION is a construction lending
AGENCY
1 hcnhy intim,Thal(here is a coumil(Sec.
lending Co.C.) for the lerlomuncc
W
tithe xvmk for which this pcnnit is issued fSec.3097, .CJ
Q Lenders Nurse
7 z Lender's Address
V 0 1 certify that 1 have read this application and state that the above alinmation is
W. correct.1 u to cum with all cit and wont ordinances and state laws relaxin
0 V to building agree,
and hereby suitorimrcpmcemad'a,of this ctry.,enter upon
IT] the oho a mentimed property for inspection pugsaes.
Pr (We).,me to mvgindemZ'y and keel,hennle,s the City of Cupertino against
W liabilities.judgments,costs and expenses which may in tiny way accrue against said
C„) z City in consequence of the granting of this permit.
SOURCE REGULATIONS.UNDERSTANDS AND WILL COMPLY WITI I ALI.NON-POINT Issued by: Date
Signtimrcof Ap,bcam/Contrucmr Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will lheappbrltmmsolum lwdofingncc.paan"I'm nr wmdlr h:eutdonx material Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and 11¢Health and Safety
Cede,Section 25532(u)]
❑Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will theapphen...mfuture I...ldingocntpant nxnegnipmentnrdavire,which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit ham dous air contaminants as defined by the Bay Area Air Quality Management
Districtt'Yes ❑Nn all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I alae rend the hem diva,n amnalx regnpements order Clmpmr 695 of Ibe
Culif..ia Health&Safety Gale.Secriam 25505,25533 and 25534.1 undersand that
if the building does not emmally have a tenaaL that it is my m,,nsibiliry to only the
csped of the requirement,which must be met prior m iso unce of a Certificate of
Occa"ncy' Signature of Applicant Date
Comer Or mthorimd agent Dale All roof coverings to be Class"B" or better
OFFICE