01050114 (2) INO
CI BUILDINGODIIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDR Si� PERMIT NO.
� 139 MEI_LO PL BUDGET PLUMBING
OWNER'S NAME: APPLICATION SUB DATE
CONNIE CHUN 28695, ROANOKE ST 05/14/2001
PHONE: SANITARY NO. CONTROL NO.
(510) 303-7847
9 BUILDING PERMIT INFO
EOCCO ARCHITEC'I'/ENGINEER: BLDG ELECT PLUMB MECH
a�W 1-1 Lu] I-1 - o
dad
Z N LICENSED CONTRACT'OR'S DECLARATION lob DOSCCIptIOn
Z,� I heathy o0iom that l ono ofmued under pend lelone of Chopur 4 iat.1 license K_ with Scnion]INNB of DivisionJnf the Business and l'nsfessinns Criteria]my license
ayy isin full gme.andeffect. WATER HEATER REPLACEMENT.
C C U License Clogs Lie p ,
Data C.ntreamr
3 ac Ia ARCHITECf'S DECLARATION
t Ra g 1 understand my plans shall IS,used as public records
m p O Licensed Prolexsional
Pilo OWNER-BUILDER DECLARATION
u1 I hereby affirm that I inn exempt from the Contmnor'x License Law far the
t Z following mown.(Section 7031.5.Business and Pmfesions Code:Any city or county
I Z C which inquires a permit to conswm,alter.improve,demolish,or repair any someone
63q reform its issuance,alwrequiresthe applicant forsuchpenniuofileasigned stmemcm
— 'Nat he is licensed pursuant to the provisions rime Comroemy'sLicense Law(Chapter9 Sq. Ft. Floor Area Valuation
(commencing with Section 1000)of Divislmn 3 of the Business and Professions Cada $600
or that he Is exempt themfrmm and the basis for the alleged exemption.Any violation
of Suction 711315 by any aplifnmt for a permit objects the applicant m o civil penalty
of am more than Eve hundred dmllim(SSW). APN Number Occupancy Type
❑I.as owner afore property,or my employ«s with wages as their role emmfornation, 3690..5'1028. 00
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business and Professions Calk:The Contractor's License Law dces tint apply to an Required Inspections
owner ofpmpert,Who bmud.orimprove,mention,and wnadcessuchwork himself 502 — FINAL PLUMBING ENERGY
or though his own employees,provided thin.itch Improvements ore not intended or
offered for sale.IL however,the building or improvement is sold within one year of 506 — G ' EST
iimpletion the ownerfb�iilder will have the burden of proving that he did net build do
mprove pupose,o PLUMBING
❑1,as owner of the properly,nm exclusively common,with It ray
to
instinct the pmject(Sm.7044.Business and Pmfcssa ns C U The Conte � r' 1
License Low dues not apply m on owner of property who builds 1 pr .sthe
end won cmmmcts for such pmjcets with a enntowlaos)lice t m h
Comosent'x License law. f t \
❑I am exempt under Sec. .B PC for this rt
Owner Data
t
WORKERS COMPENSATION UECLARATI N
I hatch,ufthm under famlty of perjury ons of the following dalmatians:
❑ 1 have and will maintain a Ceri ficme of Couseni m xelforaure for Worker's
Compsymmian, as provided for by Seen.. 37110 of the Labor Code, for the
perfomunce of the work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Luber Code,for the performance of the work fine which this permit Is
issued.My Worker's Compensation Iannounce carrier and Policy number arc
Comer; Policy N.,
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not fe completed if the permit is for one hundred dollars
($100)or less.) '
1 minify that in the performance of the work for which this permit is issued,1
shall amt employ any person in any manner sit as m become subject to the Workers
Compensation laws of Colifnmio.Data
Applicant
NOTICE TO APPLICANT:If,aline making this Certifiwm of Exemption,you should
become nosed nt the such Bow
Wotiv or
pnwisi thaof the Laboo Coda.you must
�Q 0 fnnhwith cnntply with such prwisinns nr this pcnnit shell M:deemetl revoke/.
^F y CONSTRUCTION LENDING AGENCY
tx ' 1 hereby athtm that hem is a conswction lending agency for the perfmmance
of the work for which this pcnnit is issued(Sec.3097.Civ.C.)
A Lender's Nanta
7 Lenders Address
V 1 certify thin I havemud by,uthda omtnd state that the above i alomerad is
fs r. correct.I agree in comply with all city and county ordinances and stain laws relating -
U to building combustion,and hereby authorize representatives ofthis city In enter upon ,•
} rW me above-nsentioned property for inspection pusryoas.
ti0. (We)agree to save,indemnify add keep harmless the City of Cupertino against
(n liabilities,judgments,costs and expensss which may in any way accrue again said
C„1 City in consequence of the grunting of this permit. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date.
SOURCE REGULATIONS. y'
Signature of Applicam/Conbvctor Date Re-roofs
HAZARDOUS MATERIAI S DISCLOSURE Type of Roof
Will the applicant or future building occupant sore or handle harar eas material
to defined by the Cupertino Municipal Cale,Chapter 9.12,and the I lealth and Safety
Code,Section 255321x11' '
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or enure building occupant use'aympmarne,deviees which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit haz.Mo.,air contaminants os defined by the Bay Area Air Quality Management
District?. _ all new materials for inspection. Applicant understands and will comply with
El yes ON. all non-point source regulations.
I bine rail the hazardous materials rµtdremonts under Chapter 6.95 of the
I California l le.111,&Safety Code Sections 255115,25533 and 25594.1 undersand that
if the building does not currently have o tenant,that it is my respmnohility lenotify the
occupant ofthe requirements which must W met prior to issuance of a Cenificam of
Occupancy'' Signature of Applicant Date
Owner u,summiredtiger[ Data All roof coverings to be Class `B or better
OFFICE