00040063 (3)CITY OF CUPERTINO " "^`""�"°`"'�'`� °"
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PERMIT WOWRACTOI.i INFO tMATION
,
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO{O� 0 0 4 0 0 6 3
OWNER'S NAME:
PE"hl`TL�ffn 112 0 0 0
UKEN DONALD J AND ANNE R TRU
NE:
SANITARY N0, CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Nn I am licensed under powdering of Chapter 9 (commencing
with Section 7") of Division J Of the Business and Pmfcsslons Cods. and my license is
in full mm. and effect
RE P I PE
License Class Lie 0
Dam.Contractor
ARCHITECT'S DECLARATION
I undersand my plans Nall he used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby .ff,. that 1 me exempt form the Comractafa License Law for the
following mason. (Satan 703 1.5, Business and Pmressums Code: Any city of county
which requires a Permit to cowrucL alar. improve, demolish, or repair my strucam
prior to its issuance, also requires the applicant for such Permit file a signed statement
Convactuh License law(Chapter 9
Sq. Ft. Floor Area
$5"Otion
that he is licensed pursuant m the provisions of the
(commencing with Salon 7") of Division 3 of the Business and Professions Code) or
that he u exempt dmrcfrum and the basis for da alleged exemption. My violation Of
3 4&Si44hBiberO 0
Occupancy Type
Section 7031.5 by M applicant for a permh subjects da applicant tu a civil Pcnshy Of
oat mom than five hundred dollar (SSM).
1, u owner of me popery, or my employees with wages as their sole compensation,
— pections
will do theworkinlNeswaum is nm imcndcd oroRered forsale(Sec. 70th. Business
and Professions Code: The Compactor's Limine taw dace not apply m as owner of
202 — UNDERF R PLUMB I NG
pmopeny who buiIdsorimprosy thereon. and who duessuch work himselfor hough h e
own employes, prodded tot such in,mwmcnts areoountended ar°ffemd farsak. If.
30I — ROUGH PLUMBING
however, the building or improvement is mid within one year of completion, the owner-
buildcf will have thc boom. of proving mm he did not build or improve for purpose of
302 — TUB & OR SHOWER
sale.)'
502 - FINAL PLUMBING ENERGY
O 1, as owner of the pmpony. em eamlusivey Contracting with licensed ..in. m
506 — GAS TEST
Construct the pmjen (Sec. 7014. Business and Profcssiors Code:) The Commacsofs U.
CO. taw does one m an Cramer of property who builds or improve menton. and.
507 — FINAL PLUMBING
who contracts for such projects with. conuacmr(s) licensed pursuant m the Conumlofs
License law.
O 1 an exempt under Sec. . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peWty of perjury one of thin following dechiatti s:
1 have and will mainWn• C,o Ream of Consent in self.insu ,forWorker'sCompen-
xxom. as provided for by Section 3700 of the tabor Code. for the performesra of the
work for which this permit is issued.
O 1 haw and will maintain Workces Compensation Insurance, as required by Section
37M of the tabor Code, for me performance Of the work for which this permit is issued.
My Workels Compensation Insurance carrier and Policy number em:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
F 1 MI A LE D
COMPENSATION INSURANCE
(This section need not be completed ifthef astir is for one hundmddollus(SIM)
Or loss)
MAY 0 5 2001
1 certify mat in the perfmmana of the work for which this permit is issued. I shall nor
employ any perm. in any moons, m as w become subject m the Worlrcel Compenmtian
Lawnof California. 01.
BUILDING
cant
Applicant
NOTICE TO APPLICANT: If, atom making this of Exemption, you should
provisions of Ode IaMr Cedc, you must
become subject it Woh Compensation vision of
P's
this
forthwith comply with such provisions or this permit shall a deemed reroked. .
y
LENDING AGENCY
for dm performance of
1herebyaffirm Dur Nim issued
(Sec. 3M7. .)
the wish for which this Permit H issued (Sts. J097, Civ. C.I
Name
Lend eis Add.
I cattily that I have mad this application and sou Nal the above ofornatun is
correct. l agree on comply with all city and county ordinances and sou laws relating to
pon
nd hereby NisCity mrntin
n.
U
building co)agree
mew-msnuoned Property for inspection purposes
no agatmc
noa..indemniy anmrtp homeless; the ay of apenstsidLml
L' (we) agree m indemnify tech hayinW
cmu way ccrue
y liebilitlu.judgmenta.crtsand expenses which mayor any way accrve against said City
6�
z in consequence of the granting of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
Issued by: 61%Date
SOURCE REGULATIONS.
Re -roofs
Type Roof
Signature Or ApplicanUCantracter Dateof
HAZARDOUS MATERIALS DISCLOSURE
Will dm applicant Or future building occupant store or handle haraoous maonal
as defined by thi Cupertino Municipal Code. Chapter 9.13, and thc Health and Safety
Code. Section 25532(,)1
All roofs shall be inspected prior to any roofing material being installed.
FI yes ONO
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or futum Wilding Occupant use equipment ordcvices whichodcri
mit havaous oil contaminants as ned by ft Arca Air Quality Management
all new materials for inspection.
District?
OYms ON.
1 haw mad the hxnotms materials sequimmenu under Chapter 6.95 of the Califor
1ower
ria Heal &Safet,codc. Sections 25505.25533 and 25534.1 understood that iftho Wilding
pohllby to notify me occupant of the
does not currently haw a NnBm, that it Is my re{rl
m gwmments which must be incl prior w issuance of CcNRcim of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
in.athonmd.goot Dam