01060166 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERNIR NO,
21975 MC CLELLAN RD TRIPLE A PLUMBING 01060166
OWNER'S NAME: APPLICATION SUB DATE
CRAWFORD BEVERLY A TRUSTEE 1230 PEAR AVE #5 06/28/2001
PHONE: SANITARY NO. CONTROL NO.
(650) 964-4935
O Z ARCHITEC'UENGINEER: BUILDING PERMIT INFO
p,— BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
ZZ✓_+ I hereby affirm duct 1 am licensed under provisions of Chapter 9(commencing p
�H�w wnnsecdan7oWlnrDiyiaiam3anbeBmme„ aiitlrmrel,onn,code.andmyranw GAS LINE REPAIR.
a Y e.J is full fort[mal c t. -3�j
m rt
License Lien.a
o Date Cantmcto,_ 7
a O.fi ARCHTtECFS DECLARAT
- }g I umersund my plans slug the n.d as pubic °ads
i a p O Licensed Tom..ional /
n= OWNER-BUILDER DECLARATION
1 hereby afliem that I am exempt from the Contractor's License law for the
F z< following
reaon.(Section 7031.5,Ramc'o,and rrores,hm,CodeAn
y city or county
� wl h q pten
. $300
w— Vt Iyh ) 1tf 1vanal h,Ba « Jim on,
_ ......... _ .....,_. ._ .... .
a.3N 1fL l35, h t1r( age , Valuation
or that he is exempt therefrom and the basis fm the alleged esemptio r Any violation
of Section 7031.5 by any applicant for a permit subjects the applieant to a civil Penalty
of not mote than five hundred dollars(5500). 202APNI)�M�%FLOOR PLBING Occupancy Type
❑Las owner of the Property,or my employees with wages as their sale compen.aation,
will do the work,and the atrvcwre is not intended or offered for sale(Sec.7044;
Bu,inea and Professions Code.The Cammmm',License LIw Joe,am Imply n,an 502 - FINAL PL1VME01e90s0NSRGY
owacr of property Who build,or improves hereon.and who does Inch work him,elr
0r through his own employees.provided that such improvements arc not intended or
506 - GAS TEST
offered for sale.If,however.the buildingt rc sold within one f - -
eburd`nofpro aro 507 — FINAL PLUMBING
Completion,for the owner-builder will have he burden of proving that he did not build or
improve far Pumuw or one.).
as owner of the - ... ._ ._ .. -
❑1, mammy,am Business
and treawsi ns Cai Th con,recmrs m - -
_ License the does
(See to
owner
and Profession,Codc:l The ve%Courtmemr's
License Law docs nm apply sat an owrcr-with
a contra who builds se improves th10 the
_and who contracts for such Projects wim a comranonls)licensed pursuant to the.
El l ium W License Law.
❑Tom enempt Linda Seca' ” ,0&PC fonhil rcasnn
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby offirm under penalty,of perjury one of the following declarations:
O I have ane will maintain a CeniBcam of Consent to self-imam for Worker a
Compensation, to, provided for by Section 37W of the Labor Cale, far the
performance of the work for which this permit is ismod,;;,
j ❑1 trove and will mutation Wmkers Compensation Insurance,as required by,section
37W of the Lrhnl Code.for he performance of the work for which this permit is
i.oued.AT WNOrgerC's CCmm�rva4opnounce carrier and Policy nu ber are
orriePoIicY Nnw
l: , MN ti r', LOIOZOO-6p
C . � W
RTI COM 5 KEMP ION FROM WORKERS, ... _..
' TION INSURANCE•' '
n miii section need not bereomplcted if the permit is for one hundred dollars
(S I W)or less.)
1 ccnify That in e......
..iformance of ih,work fur which ter c 'n a aro[ 1
rhino n n employ any Pena i'in any iia n as n,bee unte object in Ne Woikerd
Applicn.mtion Laws of Culifnrnil:Date trier
.Applicant.
NOTICE TO APPLICAN 1.It,after making this Ceniticam of Exemption.you shouts
Q Obecome subject w the Workers Compensmion provisions of the labor Cade.you most
forthwith[amply with Inch powixions orrhis Permit shall then deemed crooked.
CONSTRUCTION LENDING AGENCY- -- - -
work
affirm this hem is
cons(Sec. IenJing agency ter fere performance r s1'
W of due work for which this permii is issued(Sec.3097,Civ.C.)
a,Q Lender's Name
="Z Lender's Addms.u .. ... .-
U Q I ccnify term 1 have read this application and%ate that the above information is
;a,-P comet I agree to comply with all city and comms mdinarce and,tate dew,refining
O•V to building cons oundr.a ad hercbyaathorim m,mwrwdie,mmisciry toenteruxr.
r.W fere alcovementionedI.,a 1.propend for inspection am it ,hariws.,. ,
V) a.Inogmc to cost indemnify cal which
honey in he City of Cupc dmi against
_F'rn liabilities.judgments,cogs and espaf hi xbich may in any way acerae againa said
'VZ AVII-Icnmequ fir ST D thegmmingoft'ILL C.It.
r St RurcotFA no hIPUNITHA.LNONrINT Issued by: - Date
API -ICANTL D
pppPirAZARDOU5 h1ATERIALS /ZBate
. .g p• Dam
DISCLOSURE I'° Re-roofs
Will the applicant Lir future buildin ecu am more or handle h:vaNnm material Type Of ROOF . . .. . •.. ... .. - - .. .
mdefineJby,thc Cupenow Matin ipal Cale.Chapter 9.12.and the Health and Safety
Code.Station
355a2(II".p. t_/ .a . '1 ...,t + s
. a1 _ All roofs-shall be.inspected prior.to any_Toofing material being installed.
Will the appficamorfunum buddingoccupark five equipment ordicIiecs which If a roof is installed without first obtaining an'inspection, Ihgrae to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Di,tricc all new materials for inspection. Applicant understands and will comply with
EI Y" A. all non-point source regulations.
I have read the har;ndom materials rcqulrmnents under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,8533 and 25.534.l understand that
if the building docs not correctly have a henam,that ii is my re,pmdsibility to notify the
am or the ryl1uirem s xbich muxt h ten Prior to is,uance of a Cenilicate of
Occ VVVrrr✓✓✓////Il
Signature,of Applicant Date
O, antnadr.ceagen� Date roof coverings to be Class "B"or better'
._ :.t . . OFFICE .. ._