02120062 (2) CITY OF CUPEW11NO Mn'".
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:,
F I'
BUILDINGADDRESS: CHAMPION PLUMBING PERMIT NO.
10816 W ESTATES DR 02 20062
OWNER'S NAME: 2059 CAMDEN AVE. #277 APPLICATION SUB DATE:
Ah LUM JOHN J 12/16/2002
IFONE 4 O-8-T-437-15 0 7 SANITARY NO. CONTROL NO,
ARCIIFFECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
m�op LICENSED CONTsed TORS mid
,FoAi, am of CON
sup Iion70offifineatlamfineRucoderpalindessof,Code. 9mylicense,, Job Description
tai whlh auction 9NN11 ofDivisionJof the Business anJ Professions Cale.and mylicens is
in full force add ef@ct. COPPER REPIPE
0zH g= Liccnsc Class Lic.x
o Dale Comment,
nRCHITECT'S DECLARATION u tl��LM3
2 � I understand my plans shall N used as puhlic records
u6xi3a Licensed Professional DEC 2 3 2002
t-LL 0, OWNER-BUILISER DECLARATION
Wa1 mob,alsirm that I am exempt from the Contractor's License Law for the
� p O following reason.(Second 7031.5.Business and Professions Code:Any city or county
x$ which requires a Permit ,,<onsuua,a[er,improve,demolish,nr repair,any structure
=Zy poor In its issuance.also requires the applicant for such Permian file a signed stmemem
< that he islicensed pursuant,nmeprovisions ofthe cnmmae
nLicenseLaw(Chapter9 Sq. Ft. Floor Area 4YiOetion
(commencing with Section 7000)of Division 3 of the Business and Professions Cale)or
i 3
that he is exempt therefrom and the basis for the alleged exemption.Any violason of
Section 703 L5 by any applicant for a permit subjects the applicant m a civil Penalty of
OCCU
not more Iron eve hundred dollars(550x). Occupancy Type
❑L o the work,
the property, r my cmployeex with wages as th,(Sec.compensation,
will do the work,and the structure is not intended oroffercd forsale(Sec.704,L Business 202 - UNBERF 42f tic
—
and Professions Code:The Comnclofs License Law docs not apply to an owner of 301 - ROUGH Lt/tvl ectlons
pmpmy who builds or improves thereon,and who does such wurk himself or through his
wnemooyces,provided malsuch improvements arenot intended ormared forsake.If. 502 — FINAL PLUMBING ENERGY
however,Ne building or improvement is sold within one year of completion.the owner
builder will have the burden of proving that N did not Nod or improve for purpose of 507 - FINAL PLUMBING
sale.).
1,as owner of the property.am exclusively contracting with licensed conlfacon m
nswn Ne project(Sec.7044.Business and Professions Code:)The Comrecmr's Li-
cense law does not apply to an owner of pm,oy who Wilds or improves memo,and
who coronals for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Seng. e .B&P C for this reason
Owner Q?Gs.... l/. Z net...... �pst//2
JWO R'S COMPBNSATION DECLAR'AMN
' I hereby alfinn under pcnaltyof perjury one ofthe following decimations:
I bave and will maintain a Cettificand of Covent to self insum for Worker'sCompcn-
Orion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as squired by Section
37e))of the Labor Cale,for Ne Performance of the work for which this Permit is issued.
My Worker's Compensation Inmance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
phis section readmit N ComPlCted if the permil is fordnc hundred dollars(3100)
or less.)
I cattily that in the Performance of the work for which this permit is issued.1 shall not
dindoyany pmvh loannn0ra as c to come suhjcn it,the Worker.,'Compensation
Lawsof California. 16nZ
Applicant
NOTLAPPLICANT:If,after making this Certificate of Exemption,you should
Ncnmc sac act m the Worker's Compcnsminn provisions of the Labor Code,you must
O O forthwith comply with such provisions or this Permit.Lll N deemed revoked.
z CONSTRUCTION LENDING AGENCY
F I hereby affirm Nat share is a construction lending agency for the performance of
1' the work for which this Permit is issued(Sec 3891,Civ.CJ
a Q Lender's Name
Lenders Address
U Q 1 certify that 1 have read this application and state that the above information is
Isr F correct 1 agree Or comply with all city and county ordinances and slate laws rclaud,m
�U building construction,and hereby aulhonad representatives of this city to enter upon me
oned
purp
abovoms,judgmentproperty. set rand expenses whichsma
FC (We)agrec Or saw,indemnify and keep M1artnlcu the City of Cupertino against ' /� NS ,
' N liabilities,judgments.costs and expenses which may in any way came against said City
U Z inconsequence nfinegranting thnhispermit Issued by: Date
�-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCF.REGU ATION&
. macer fApplicatal nhmClor / OzFe-roofs
Dale
IIA ARD
OUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building Occupant store or handle harardous material
as defined by me Cupertino Municipal Cale,Chapter 9.12,and the Health cad Safety
Cuda.Scaion 25532(x)1
C3 Yes RANO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hm.amous air contaminants as defined by the Bay Area Ab Owl ity Management all new materials for inspection.
DGlria/ P
❑Yes ?ZNo
1 have mad the Imsardnus materials mi,mo meats under Chapter fi 95 of me Califnr-
nix Health&Subtly Code.Sccduns 25505.25579 and 25534.1 understand condole building
does,not cuwnlly haw a tenant,that it is my rapomai hit by In oddly the occupant of the
requrmenis w ieh must N met prim m issuance of a COlifieme of Randy. Signature of Applicant Date
fs/ 2 All roof coverings to be Class "B" or better
Owncr rautlmrlyed gam Datc g