00080138 (2) CITY oFrnN
PERONo
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10799 E ESTATES DR DAHL PLUMBING CO S3HN F 000801.38
E:
OWNER'S NAMAPPLICATION SUB DATE
SHEM THOMAS D 329 ALMA ST 08/1.8/2000
ONE: - - SANITARY NO. CONTROL NO.
(415)321-5500
alARCHITCCVENGINF,ER: - BUILDING PERMIT'INTO
be BLDG ELECT PLUMB MECH
NZw 1
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Z�tVK LICENSED CONTRACTOR'S DECLARATION Job Description
O Z_e 1 hereby affirm Iha,I am licensed under pmvisions of Ch irmr 9(commencing
In L:J withSm,inn 98089of Dirision Jof the Business and Pmfcssions Code, dmy license
is mmnro11ove FURNACE/AC
s a License Isle,pu,
°' n O Dom r.'nmramn
���and m RCicallEe use aI PanRAecord
(: 0 I understand my plans shall he used ae publiv records
of
p O Licensed Professional
a°J o OWNER-HUILOLIt DECLARAf[ON
u'1I I humby affirm that I i exempt Jinn,IM Gm,memr'x License Law fnr the -
C Z C following rcmon.Smartt 9831.5,Ilnslnesa and P tic viom Code:Any City or county O
Sit F O which regnire.+u permit m cons,mn,ober,Improve,demolish,nr repair any+maim e O
63g prior to its issuance,also requires[be applicant for such permit to file a signed statement
that he is licensed pufsccuum he pmvisions or the Conlmgors License law.Charm,9 Sq. Ft. Floor Area Valuation
(mounio ncing with Station 7000)of Division 3.1 he Business and Profession,Code) -
ar that he is exempt therefrom and the basis for the alleged exemption.Any violation ?
of Section 7031.5 by any applicant for it Penni,subjects the applicator to a civil penalty
,if not am than five hundred dollars(s5IX). - APN Number - Occupancy Type
C 1,as he,of he property,or my employees with wages as their are compensation, 9
was do The work,and the structure is no,intended or offered for sale(See.7M4, Required Inspections
Husi aw s and Professions Cale:The Carl...,,,a License Law does not apply cian
t
swam of property Who builds or Imports thereon,and who does such work himself '
t.nfrnrgn his own employee, pmmded mm+inch improvements faream infrared nr 303 — ROUGH MECHANICAL .
officer lin sale If,however.,hr hulldbig or iii,ovemen,is sold within tote year of f
conaliletion,the owrombuilder will have no ficarclen of proving that he didnia Wildor 304' — ROUGH ELECTRICAL
improve for pumoscofadc.),
❑1.asowner ofine pmperty,mine"I.simlyaattractingwith Bcensedroadacmrsto• 505 — FINAL ELECTRICAL
consumer the project(see.num,Bmim%s and I'mfexsions Code:)The Contractors 508 — FINAL MECHANICAI_
License lax•does no,apply,o an owner of property who builds or improves thereon, '
and who contracts fnr such p.jcc,s with a commemrfs)licensed refs....to,he
Contractors License Law.
❑1 am Comfid under Sec. ,B&P C for this reason
Cisco, Date
WORKER'S COMPENSATION DECLARATION
I hearty affirm under Penally of fail ary mm of We following dmbi,ation5:
J I have nn I will moinmin a Crniticmc ni Cement to self-insure fnr Wu.ear's
Compansntinn, m pmvlded for by See dnn 1700 if ,M1e Labor Code, lin' the
pertimnnnce of the work for which this st is avucd.
C I have and will maimmin Worker's Confpensation Insurance,as required by Section
J9010 of.he Labor Cade,for.M1e performance of the work for which this Pemfi,is
issued.Aly Worker's Compensation Insurance carrier and Policy number are:
T I'olicY Nn.: /
?
CE IFlCATION OpfIXBMI'TIO FRO�OR[CE� '
COMPENSATION INSURANCE
(.Tis section need nm be cninplemd if he permit iv crime hundred dollars
($IM)or less.)
I certify that in the performance of Inc work Ibr which this tarmO is issued.1 -
.xnall to cani loy any person in city a t>o as m bcmmc acave,m the W..ken' -
Com"a'mion Laws of California Lou,
Applicant
NOI'IC17 TO APPLICANT.If.after making this Cenillea,e of Estonians,yon vnoud
Q 0mM1cnnc subject to the Workers Compensation provisions urine Labor Codc,you must
forthwith comply with such provisions or this permit shall W deemed revoked
FCONSTRUCTION L ENDING AGENCY s.
1 hereby affirm that there is a construction lending agerry for the performance
of the work for which this permit is issued(Sm.3097,Civ.C.)
L Q Lender'.,Name
i1. Z Lender's Address -
V 1 renify,her I have read his application and,met,ha ,he above information is
LL Fa
correct.I agree to comply with all city unit county ordinance+aad.state lawn(dating
Q V cit buildingmnxuaction.and hereby xmhorimrerreenm,ivea ofthrs city,,,enter upon
Iheadawo-men,infood prapmy fnr mvpewion pov,ow,
L 61x (W,)a,am to save.indemnify and km,aconites the City of Cupertino agent, -
ffrr V) liabilities,judgments,Coss and expenses which any in any way accrue against said
C.7 Z City in conviamence of the gmming mf,hi,percon.
APP It ERST SAND WILL COMPLY WITH ALL NON-POqI T Issued b : Date
OE _4 � Y
signaMo,n p teanocantaemr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will he appti..t or future building o..Pa.,stem or handle hazmdaus mamrial Type of Roof .
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Sema.255320)? _
ores I7 No All roofs shall be inspected prior to any roofing material being installed.
Will,he applicant or boom hit Wring mcapan,use cquipmem or devices which
alit hrlardmr<anrnalearrantsa.deened h'me Ba Arm Ah yManagementIf a roof is installed without firs[obtaining an inspection, I agree ro remove
y y Quality la f g I
ixmet? all new materials for inspection: Applicant Understands and will comply with
°Ye' CN" all non-point source regulations.
1 Lave mad the hmardons ran....1,requlronems under charter 6,95 of the '
California Ilealrh&Safety C,de,Scainnv 25505.25533 and 25534. understand Nm
if the building does not cu.remly have at Ienam,,hal it is my responsibility to notify the
oocupmn of the na,m mems which must he nal Prior,o issuance of a Ceniberte.1
Occur..
Signature of Applicant Date
IJ
GzIIErn rages, Date All roof coverings to be Class "B" or better
OFFICE