02040062 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT OR-INFOItMAnON ,
BUILDING ADDRESS: PERMIT N0,
22771 A MEDINA LA TRIPLE A PLUMBING 02040062
OWNER'S NAME: APPLICATION SUB DATE
VAN BUREN KAREN H AND PAUL B 1230 PEAR AVE #5 04/15/2002
PHONE: (650) 964-4935 ANITA
SRY N0. CONTROL N0.
ARCHITECTIENGINEER: BUILDING PERMIT INTO
w BLDG ELECT PLUMB MECH
K.= LICENSED CONTRACTOR'S DECLARATION lob Descrition
Z_ I hereby dm frthat l am licensed under provisions of Chapter 9(eommenein$ p
_t withSec,ion?000)olDivisionJofthcBusinessandProfcxxkmsgode.mdmylicenu REPLACE 2 WATER LINES .
,sin ion mree and
,. r n-
¢ < License Cla s .- 3 G Lie.is .i g S f
O c U Dale ( Conlnmor
uC� ARCHITECT'S DECLARys
5 1 urdernwd m)'Dlans shall W used az publi rc rdY x•
E o O Licensed Professional
OWNER-BUILDER DECLARATION
u�M 1 hereby affirm Na,1 am exempt from the Contractor's License Law for,be
t z< following reason.(Seelion]0715,Business and Professions Code:Any city or county y�15
s o which uircs a construct. rove,
Permit to construct.alter,impdemolish,or repair any structstructuree
ro
3$ -Po its issuance,also retdtKc h isionantfonuch on=toit Licensle ae ed aw(Chstatement
NSi he u.l td led pars int So Ne prMislons of Ne Conlrxton License law(Chep, 9
(comment ngw NSection30P0)of D' sion]of the eusineu 4td Profeutom Code) t, t- � r..'�'6ty "t'j�,.,' Valuation
or Nat he a esempt I oo,,,Z a t the basis for Nc alkgedexkmgah.Any vtolnion
SS
f SeNon-7W L3 by any appli.mfi r o perm;,subjects the up irm,mrs shell .try N'
onotnuo th;np,,,Wnmaddena>=S,.) 202�N U rRFLOOR PL MBING'0 Occupancy Type
❑I,as owner of the Property,w my employees with wages as their sole compensation, _
'wi sinesdii a wdrk:odd the ode:T e is no,m is Linded ease Lawrcd doe idle(Scappiv toa n 502 - F I NAL P $4�sp$gt1MGY''
owner of and erty,W Professions Code:The Commcmou Licence law docs not eyply i rn
muter of property,Who lolees m improves Nc such
i and who does such wink or
_.q lhmagh his.Ir,employees,provided uulepeh imgoyegems are nm intended yyear or. ...._..5.0.7._-._--F I NAL._P�U.MB I NG_;__..._..---_,__'------ ---------
�complle for uk.IL Wwuilde w building or-;men ofp n,n sold wi did mK Yea,of -_-'-- r,�,i..qv ;t) G.ifcs;pC _----
omple,ion,Ne owner-Wilder will have she burden of proving that he did not build or
improve for purpose of sakJ. �
Dl;as owner oLthe property,am esdusivdy contracting withliccmeJ contractors to i li_,,'._ __ f'_-..--_-__--
6 cmitmm the project(Sec.7044,Business and Professions Code:)The Comrvclor's ■q-
+- ,. .c _L„
License law does nm apply m as cone, d propoly who Wilds m improves Neon
cr , /��" i:t i.: _ 1 .
._and who s..fe such gojectx W c uaua(q da nsed•Pursuam to the-
Concrachus Liceme Lsw. —
❑lamumpt under yes T' "'ek P C for this ion rS pIT '� 6 200E !'1 C• a :)..
Owocr D. tr, at,.._WORKER'S COMPENSATION DECLARATION , { 1
r- ):•.`.-i hereby affirm undo pelWryl°f Pe�urY-one,of du following deeluatiov:--- BUILD1N G
❑ 1 have mil will'inainuib fCcnificam oYConxmi io'self-insure fm Worker-s
Compcnutiour as,-provided for by Seclion-37W of the Labor Cotler-for the
performance of Ne work fm which Nis paimdt is issue.—:r,,
❑1 h ere 'Mi iII mdinum Wo,ker s Coippc s t on InsurttKe,as rryVirtd by Section
r. 3700 6f,he Labor Code,for the perfornomo of Ne twork lo:which.tbla pemdt is
slued My Wddecrs Compenutronl urine' ante uld Poli teethe -
Cert)
l '.CERTIFlC TION Of EXEMPTION FR MINOR hr, :.',. " ' 1
a
do ..
fTh a seamn nttd not Yc completed if the pmnil ix lm one huMred llars �-�„�'+.:`+ j'✓'JC y
f3100)or less.)1., ,-
._.---------- ._._. ------- ____.._...-------
�r'-r A I amfY Nat n the perfonnane of Nc eek f h¢h Nu pc n Is usuida r r.,,.. . f,,i,,. :t..+:' __—
iAoll not employ any person n'anY an s rss to become s b)ect ta)lte Worker%
CoMdenseuon laws ofCabfomy Dee
._---- ______ --
on
:NOTICE TO PPPLICANT If afu rgoling,hpro"un, ofE mpuon,,,y6u mind JI F.4' .. '�,-'t's”
bi'cowit cjccuo•Ne Wtich provisions
or tion pmmii shall
the Labor revOked. must
z C, forihwidi comply wiNNsueh provisions or this perm;,shall be deemed revoked.
Z _M-f. -_ ___ _..... .._.._... __-_...____..__._-.. . . ... . .. 1 _
"'ITfn t?C`a R :":f"CONSTRUCrIOVLENDNGAGENCY' ...__ __ J.•: .
•0 _ 1 h by Rlm N t the co sI.wa o ltd g jetty farNe,pertofmance r
�'- fNe coo
Or which Nspc sts ;sued(Sec9997 C1 Cj -
(idersNarne-.....,... ...xa -... xF._1i,.r.,_. --------..._.. _. _.-1.__._._ -..-.-... ._...... - '
p'N ;seders Addres -
ld,: Icertify thin I hread this me,
tlsli ..uh "W font don is
O:E torten 1 agree r.,ru .' N ell ry rut o ty ordma to ar,d sl t Im Immg
O U, :ho
W Idng nswet andhe by thw p sensed es if this city to este upon _
� I„t Ne aW. mon d property for inspection purposes.
.r C+'.1 IWe)ag eet C Inde - fy Nd keep harmless lh Ciry Of GYgn'O gtinst rLr
h habil t es,7 dgnsems.c and penis xh ch mal ,_ r way avcro gatmlksaid II L`a
U �' City cd uquk a oT mqunp of Nis gmntt - 1
s ICe TL' an T s u;14rr co sltr„tTil L'�f':SSol Issued by: r tl .` t
st Rof APP,canVContne,er r- y t - Dpm'0'1; Re-roofs uu U
t� HAHaRD0U5 MATERIAU DISCLOSURE ! IT: ".
p- ' WII Ne eppbcaht mfum Wddmj pmt uocmh elk harallo mmnaf _ Type of Roof•-. _. �.
u Defined by the C promo MumclDil Coda.CNp,c 9 12 and the HeilN aM Saf ryIt '_ _'"_
Luk Semon 751338).j 7 v �... T fr31 , m i i t , 'i ' li 1'. f i 1 1. ;C \ !Li, t;- IrSsy
❑res aNe u _All,roofs shall be Inspected prior.to.any.roofing.material being installed._
�v
' Wth Ne apDlic?n_,o furore Wdding occupa, quipmrnt o a ae5 which If a roof is installed'ivithout first obtaining an inspection;'I'agiee(o`Lehiove
m - - Qry Mang
District?
msON fmWb 3 Ne Ba r Art.Ai uilleme n
I _all__new•matenals.forinspection.nspection Applicant under standsand.willcomplywith
- all n n- Di t s ere ulauonsq. s:
a t,'q 1'lu a read Ne harallous cop, els rtgmrtmenu:u der Chapter 693 of Ne
Cabfo u Health r&Safety Code S trans 33503 33533 and 33374 1 Mersund Net „ ,.,,. ./• ., �-
JRie bwldln$doei not_c dyhiciuwnl Nn a mYrespouiblrymtmufy the l
ocm lords rtqu ,which must W met,poor an mvuame of i,Can,Ocate'of
e/� 1 1�.L .... Siguiture.oIrApplicant .-. ._ .__.. .. Date -
o •Ih u cage t a „ Dme All roof coverings to be Class'B"or better "
..
: . , . . ...._....OFFICE....-.�.. __ . - . ' - ' ". . .. ...._. . ........ . ... .. ....