01050184 (2) .. CITY OF CUPERTINO'
` ❑unanNG DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: ` - '' PERMIT NO.
11135' LR PRUPW DR BUDGET "PLUMBIN6r. '.. . ;, : 01050184 -
OWNCR'S NAMH: APPLICATION SUB DAPI.
PIRRCHRNT
�' - � . ' -JRNET R: a. .-;_.;''• , .;.. n , 28695:;RQRNOKE-$Ty-,, �;�. 05/25/2001,
PHONE. I SANITARY NO. CONTROL NO. -
1510),303-7847?
❑c Z ARCHITECT ENGINEER: BUILDING PERMIT INFO
O - - BLDG ELECTPLUMB - MECH
Z�y� herebyaffirmLICENSED CON]RJCTOR'DECLARunder provioms ATIN
Chop 4( ane ns Job Description
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at I
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with Scent ]fNxlj f D J f the B acs+unJ Pndn"ons Cole,mA my sense
a L''verialcm.r duet c a NRTER•.'HERTER• REPLRCENENTI;�--
LL H Date' Coal unur 's
ARCHOHCI"S DECLARATION
O-a 1 undersand my plans shall be rased as public records -
y 95 O O Licensed Professional
x OWNER-BUILDCR DECLARATION t
ul=' 1 hereby aRrat that 1 am exempt from the Contractor's Liceme law for the
following reale...(Senium 70315.Business unJ Professions Cale:Any ciry ruammy - - -
P C which requires a pemtit to construct,ahcr,improve,demolish,or repair any structure
ut
aim poor'.la issuance,also requires theapplicant finusch permit mo file o signed statement
that he is licensed pursuant to the provisions.file Contractors License Law(ChaNcr 9 Sq. Ft. Floor Area Valuation
mme
(concing wilb Section 7000)of Division J of the Business and Professions Cale) ,
.r that he is exempt therefrom and five basis for the alleged exemption Any violation _ - - ;$550
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mom than five hundred dollars(S50B). APN'Nu tuberOcdupancy Type
01.a,sawncrof the property,,my employees wilt wages as rheic sole compensminn, 35516035. 00
will do the work,and the structum is not intended or offered for sale(Sec:]f W, -
Business and Professions Cade Tim Croissant,'.,License law it.,,amt apply,.an Required Inspections
orcaner of properly Who builds or improves thereon,and who does such work himself
through his own employees,provides]that such improvements ere not intended or ` •502 — FINRL 'PLUMBING, ENERB.Y -
offered for sale.If,however.the building or improvement is sold within one year mf SOB — GR$ TEST
,th -
compietio.theowne,holJerwillLaveNe burdenofpm,irathedidnmbuildor -
improve for purport of cale.,. - F =
❑I,as ownerofrhe properly;am exclusively contracting with licensed con Imachines PLUMBING-to - - -
Lonsuucr the project(Sce.70TI,Business and Pmfession.s Code:)The Contractor's '
icense law does a.,pppty to an owner of pmpeny who builds or improves thereon.
pmjau APR 2 9 2002 '
`and who contracts for such with a comrumrR)licensed-purl am m the ,
Contractors Lireroe Law.'
❑1 am exempt under Sec. B&P C for this ream. ,
Owner DateBUILDING'
WORKER'S COMPENSATION DECLARATION p -
I hereby affirm under penalty of perjury one of the following declamtionr -
❑ I have and will maintain It Cenificmc of Concent to self-im m for.Worker's - -
Compensation, as provided for by Section 3700 of the Latus Code. for he
:perfonnana
cifflan work far which Nis permit is ismes].
111 have and will maintain Worker's Compensation Insurance,as required by Section _ 1
37W of the Labor Code,for the performance of the work for which this permit is
issued.My Worker's Compensation Insurance carrier and Policy,number are:
Carrier: Policy N., - S -
CERTIFICATIONOFEXEMPTIONPROMWORKERS' s
• COMPENSATION INSURANCE '
(This onion need not be completed if the Perini[is for one hundred dollen
.(S 100)or less) s , I
I certify,that in the performance of the work for which this permit is issued,
'hall not employ any person in any manner so as to berme subject to the Workers ,
Compensation Laws of California Date -
Applicant - -
NOTICE TO APPLICANT:IL after makinr this Cenircme nl Exemption,you should
become subpet tri the Workers C...pensatan pas s nm of tae Labor Cale,you must
f.
z
mot comply with such provisions or this permit shall he dcemeu revoked: ,
(~ ln CONSTRUCT ION LENDING AGENCY ,
tui } l hereby affirm that there is a confound..lendingugcncy for the pi Iran. _
of the work for which this pemnit is found(Sec.3097,Civ.C.)
4 [) Lender's Name
.D z lender's Address;
V I certify that l have read this application and state that the native information is
O [., ,,,act.I agree to comply with all city and county ordinances and state laws calming
V no building construction,and hereby authorirc representatives of this city to enter upon
.} the uM..-mentioned properly for infpcaian purposes
(We)agree to save,Indemnify and kap Lunnlesf the City of Cupeni.n against - -
F.'W liabilities,judgments,costs and expenws which may inlay way accrue against.said 1
U City in consequence of the gmabng of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT Issued by: Date
SOURCE REGULATIONS. y'
Signs rat of Aodicum/Conoator Dare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
.wu Neeppficam.rfa.re building aenpam Rare ar hada tatoods mmudai Type of Roof i
as darned by the Cnpali.n Municipal Calc,Chapter 9.12 tad the Haulnm and Safe,y
Coda Senna.25532(a)'Y -
. 71 Yes 13 N6 All roofs shall be inspected prior to any roofing material being installed.
Will the appllca�t or quare building cecupant,ase arvlpment or devices which It'll roof'is installed without,first obtaining an inspection, 1 agree to remove
mnh hamrdous air conanni ants as defined by the lay Arta Air Quality Muatge.em
Dtarmr' r - - .allnew materials for inspection. Applicant understands and will comply with
0Yzs " No
, ' , - . all non-point source regulations.
I no ve relid,he hnzoNaus n antral,r,inucmem,under Chupar 695 of the -
- California Hcalth&Safety Code,Sections 25505,25533 and 25534.1 undurmiind that '
itthehnlldingdnas na currently hnve',i cnnnL Nat it is my responsthilitymnmlfythe -
- xcupam of We mquir mrntx which dntsf he met prior ro Issuenee of u Cenircalo ud .-
Orcupnncy, - r -
is
Signature of Applicant Date
owirara-nunmHaed ago;,, - - Lima . I All rciof coverings to be Class `B" or better -,
.. ,i OFFICE
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