00090071 (2) CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUIhDING AUDREtiS: 5
}�'<� (� ,,n SANITARY NO. APPLICATION SUBMITTAL DAT
yr INQt�t7tu QA i �� I�
o E 's NAME: `�f^O �YALT F'L IMBING IZaa9Qa71.
l!L NIC CONTROL#
'T'3 DSL�i (`lemS�'1 c�0 �' ED Ela9i1.3i2aaa
wk',. ARCH]rECIENGINEF,R BULDING PERMIT INFO
00 (408) 267-9330
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a I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I em licensed ander provisions of Chapter 9(commencing Job Description
F`J C w with Section Division 3 ofthe Buslress and Profedmru Code, dmy licence is
in full force end a (�
3 t, It tae Connector `/" I I r t' 'PER
ARCHITECTS DECLAR ON
�}
1 in dentond my plans shill w used at public records
i a rc hewed Professional
OWNER-BUB.DER DECLARATION
1 hereby affirm the I am exempt from the Contractor's License Law for the
d F m following reason.(Section 703 L5,Business and Profusions Code:Any city or county
w 3_ which con,ri a permit in,construct.alcor,improve,demolish,or rtpilr toy Structure Sq. Ft. Floor Area Valuation
prior to its issuance.also rtquircs the applicant for such permit to file a signed statement
that he in licensed punumt to the provisions of the Coun ermas I.icenre law(Chapter 9
(commencixemwits heeirom and)of,Division of meOur
eged exemption
Professions Cadeof 3/ efsN� ber .-g Occupancy T
that i is 31.5 b therefrom ora the buil for be alleged exemption Any violation of !,/J' (/ e / P Y a 0a
no' on then by any applicant fora permit subjects Ne applicant to.civil penalty of
not mom Nen oft hundred props dollen y employees
El I,down«of dd property,at mycmptuyecd wiltwages utheir sole 7044, nnness 3661�Ml1i:e6�spections
will Pr lie work,and the structure is nor,Ince
d w Law
do for 0l WI, )Oso,Business v
and Professions Code:The Contractor's Liunw law d«s nd apply s lf owner of
progeny who builds or improves Narcan,and who doer such work himself or mrough
his awn employees,provided Ne such improvement,art not intended or offered for 106 — SE,WjE R & WATER
esic.If,howmer,the building w impovemam is sold within one yurafcompletion,the �EU,{TT�t���1�//jj
idd oral have me"men orpwamg N.t he am not was m improve r«tor- j _ BE - P P - PING
❑poK or dm.). ���IJ J�tJI�-- _
1,as owner of the Porten,.am exclusively connwting with licensed comracmn to — GH PL
pittmct the project(S..TWI,Business and Professions Cde:)The Connectors Li- TU & OR SHOWER
come law noes mit.#ply w m owner or propmr wino soda or improves theean,w�
wM cmuacufm such pwj«u wiNauntrwt«(r)licemed porsumtto Jre Crnnedore 502 — FINAL PLUMBING ENERGY
License Law.
❑lam esemptanaersec. ,RSPer«Nice recon 50E — GAS TEST
Owner Dee 507 — FINAL PLUMBING
WORKER'S COMPENSATION DECLARATION
I hambY alfonto nder penNty of parjury me of me follewing declomi«u:
Ili. ,sed will for
by Saw...37M
of Obse onto Conde,forcfor Wodeta Compere
utlon,as provided for by Secdon 3]00 of Ne Labor Conde,for the petfomonce of the
work for whim Nis permit is issued.
have eLa will maintain Wittier eofteCompensation work
for whi u required by Section
3]00 o(ltc lobo Code,/«Ne perfwmaeee of Ne work for which this Permit is:(cord.
My worlatrx telnnspiiW.1urancc carrier and Policy="
M
Came,:�q tC.Jr� I Policy No,ecru wruJa�O••LTIh
CERTIFlCAM OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(Ibis s«tim reed not w completed if the Permit is furore hudrd dollar,(SIM)
or I<u.l j
IcenifytNtin the performance nl Ne work for which Nis permit isioud,ishill
not ere,my wY noun my no a#�vadja to Ne Workers'Co.,.-
action '^
Aicant oflll(ro�Ptia are (( VV VV vO
NOITCE TO APPLICANT:IL eche making this Cerin s o of Lam,Coo .' should
became subject1. it Warkde Compenr this provisions of One Labor Cde,i. must i
forthwith comply with such provisions m this permit shell be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q I Worthy aim mo Nee u a consumcdon lending agency for the performance of
Z 2 the work for which mid permit is issued(Sec.3097,Civ.C.)
to Lendeen Name
=,'s Address
k: 1 unify that I have read Jds."].cation and arae that the awve infomomm is
0. nowt.I agree to comply wilt 01 city and county md dinences aado laws.1mrig to
.7 Z building crnsuuction,ed hereby aewriw repment,tivn of this city to mor own the
U .hove-memiond property for inspection purposes.
;1 E.,a (We)agree to save,indemnify and keep harmless me City of Cupertino against
C U Iiebilair.,jdgmems.cut."a.psmes which may in toy way acesuea,mot did City
>. W in concepts..of the grmdng of Jde proun.
[+ 0. APPLICANT UNDERSTANDS AND WI LL COM PLY WITHA LNON-POINT
IZiUx SM r,RLf.TA'llr NS3 ^/ �
Sigruumuf ApplicmVComract« N[I/`/�f Doc �/
HAZARDOUS MATERIALS DISCLOSURE )
Will Jun applicants or future wilding occupant store or handle hazodons material Re-roofs
as defined by the Cupertino Municipal Code.Chapur 9.12,and the Health and Safety .g�,pC Of ROOt
Code.Section 5321x)] / / ''ll
Dyes la
Will the applicant orfumm wilding mcupmt use equipment or devices which All roofs shall be inspected prior to any roofing, material being
rmt,Incordau,airmn«mine,nasde.ndrcarQuaManagement by installed. If a roof is Installed without first obtaining an inspection
itriet] I agree to remove all new materials for inspection. Applicant
❑Yu
understands and will comply with all non point source regulations.
1 l.1 od-Se materials)5,255 tent,oder Chap«6.95 l .1 Cali
I. i Heal f C tine 23305,25533 and 2553q.1 undentmd Net R the
hu i ing have tenant, tit is my sTac ity moot:(,the«" nt
Pa
1. e ofa ¢ate or u
r Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE