02110145 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .
BuIi1)"b%YI9EsffOHNSEN DR. CUPERTINO PLUMBING PER MITN(02110145
ownW MADORNO 10297 S DE ANZA BLV APPLICATI1Ti/vpgY2002
IFZONE (408) 253-0618 SANITARY NO. / CONTROL NO.
ARC!IITEC IENGINE¢R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LIro Mm Ilt CON'IAACTOR'SDF.CLARATION
therenyalfifmthat lamf the Bi uctlend vishma o..C.d,. 9hommerxcis REPIPE�WATER S T/s� hon
tui1h11lomn elthof Division lnl the¢usinese and Professions Code,and mylicense is �+
mom in lull lircc unJ dlccL Z� �C� S— PIN/�,LE®
g? Liccnae Chas Lie.PinPintp Dam - 'C - Contractor- Y
�pw j Ion sta ARC151 Muscda'uhlia c o s
I
= ,— MAY 12 2003
Li� JPn sln OWNER-BUILDT: EC ATIDNt��1 her fiy affirm Ina(I ma escmpo ft Cortramm's License Law for theBUILDI[j111Io0
following reason.(Section 7¢31.5,Business and Pmfcssions Cook:Any city or county which re(hines a permit hs construct,alter,imphow.demolish,or repair any structum
1eprior to its issuance,also requires Ne applicant for such permit to file a signed statement
Nat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q53.T%FvdAIQ0 Valuation
pF0 (commencing with Seclion 701gp of Division 3 of she Business and Professions Codr)or
al ca r3$ that 1e is exempt therefrom and the basis for Ne alleged x,mn ion,Any violation of
Section 703 L5 by any applicant for a pemllt sub*"Me applicant In a civil scrohy of PN'N OCCU ane T
not more man five hundred dopers(S500). 301 — ROUGH PLUMB I G p y yI�
❑Lo owner , lad Pmscny, remyemntended with Bred for
afe(Se.tM.Business
will do the work,end the structure is intended aro w do finagle(Sec.7lla4.Business
end Professions Code:impTheroves
ves Connector's and
who Lew such
Ins apply lf an owner of 507 — FINAL gt CCh0a5
own coy who s,pro of ed that such improvements,
end who am not ch work or offmlf or through his
own yer.M building
provided prouchimprovementsatenot intended or for sale.If.
however.Ne Building or improvement is sold within one year of completion,Ne owner
builder will M1ave one burden of proving Nat he did not Wild rr improve fur purpose of
salad.
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.71144.Business and Professions Codc:)The Contractor's Li.
carom law doses not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. ,B A,P C for this reform
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby alliem under Penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent o self-insme for Worker's Compen-
f alien,as provided fnr by Section 3703 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 required by Section
Tial of the I.ahnr Code,for Ne Pefformence of the work for which this Permit is issued.
My Worker'sffC�LLompensation Insurance carrier and Policy number are:
460 CBR1er. S,IIJfG �r✓y� Policyblo. If UI IiAjIT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhesection need not W completed if tW fermis is for orc hundred Jollam n lap
or less.)
I ccnify that in the performenee of the work for which this Permit is issued.I shall not
employ any person in any manner an as to become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making Nis Cenificam of Exemption,you should
become subject to she Worker's Compensation previsions of the IaWr Cole,you must
OO forthwith comply with such provisions or Nis Permit shall rte deemed revoked.
n'Ea "" CONSTRUCTION LENDING AGENCY
[-� .�., I heathy affirm that there is a construction lending agency loathe performance of
tY, Ne work for which this Permit is issued(Sec.31197,Civ.C.)
131 Q Lerdch Name
z Iander's Address
U Q I ccnify that 1 have read this application and stem that the above information is
Correct.1 agree to comply with all city and county ordinances and state laws relating to
� U above-mentioned
herebyauthnnprepresentatives of thiscity toenter upon the /
n7 ahnve-memianeJ Property lin inspection purposes.
d (We)agree to suss indemnt ny and harmless the City ofmmno against
.F"y fn Iiabilitica,juJgm IS,'sa ands ses ich mayinanyy accrue,agaios
accrue, nstsaidCity
U z in to
cncc L((hc gr ting This pc it.
APPLI ANT NOE TAN S'AN W LL C PLY WITH ALL NON POINT Issued by: Date _Z, O 7�—
SOU L R UL•AT NS.
Re-roofs
-Siof ppmmh9 mnnlhi1' SDISCLOSURF. Date Type of Roof
IIAZARill the applicant or future building occupant store or handle haurdous material
m defined by be CoMmi�`1\M—unicipal Code,Chapter 9.12.and the Health and Safety
Code oyf9 zss3xarr wlNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr from building occupant use cyuipmcm or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hatemoux air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection,
Districd
❑Vcs No
havere:yl rbc h:, mens amrialsrcquircmcnm under Cnapmr6.95 of the CuliRm
Biu lluJth S Sa'ty , ,,actin '25511,25533 and 25534.1 understand Nat ifthc hnildbtg -
do es no curt Oy hu u sena Wn I Is my responsibility to ofel ono occupant of am
require cel .w uatbe Et Po sten faceniecaterfaeupancy Signature of Applicant Date
�/ S ez All roof coverings to be Class"B" or better
her a urif. agent Date