02100012 (2) CITY OF CUPF,BTtNO k .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ,
RuiQ)l9(&5l*EsMERRITT DR CUPERTINO PLUMBING PERMITN®2100012
OWG01iiCME-CLOUD 10297 S DE ANZA BLV APPLIcNITh0hylryflTIY2002
Ali
ONE: 4 0 8 2 5 3-0 618 SAN["fARY NO. CONTROL NO.
41
ARCHTEECT/17NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI
ma, t�
LICENSED CONI'RACI'ON'S UFALARA9lON n��
.00 I hemhy affirm that lam licensed true,pmviUmxof CM1apmr v(Ommcncing COPPER REPIPE�TSff1rh21TER
;mayw wim Section71xx8 of Division of me Business and Professions Coce,and my license is
imm�fnr<anucfrect. WATER SERVICE
0
pz Lice
clax. 3L Lle.x L23170T
iyF❑ Dmv O.P Contras r t- PL✓/s-/R
ga �ARCI31'LCI'SD. 'ION
l under' it y I'n 'O
Wusc spubli it
coyU
53wy Lic'crocd l' Irl
O< OWNER BUILDERRATION
I hereby aflirm that 1 am exempt from[tic Contractor's License Law for the
tirp<O following mrsoo.(Section 7031.5.Business and professions Cole:Any city or County
x$ which ov,m a permit to construct.alter,improve,demolish,or repair any structure $5000
pmoIn m osuancc,also requires the a pplisnt fofsuch permit to file a signed datemcm
that W is Ecemcd pursuant,the provision Of Contractors Uceren Law(Chapter 9 Sq. FL Floor Area Valuation
I$ (Commencing with Section 7o00)ofDivision 3of the Business and PrnfesSomsCode)or 31635003 . 00
y _ Nat M is exempt therefrom and the basis for me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects me applicant n a civil penalty of APN Number Occupancy Type
no,mere that fire hundred dnllam(SSm). 202 - UNDERFLOOR PLUMBING
1,as owner of Jct pmpenY,or my employees wim wages as their aIle compensation.
will do the work,and the structure is not intended proffered forsale(Sec.7040.Business
and Professions Code:The Contractors License law docs not apply to an owner(if 502 - FINAL eRGY
pm,amy who builds or improves thereon,and who deessuch work himulform i ugh his
Own employes.provided that such improvements am not intended m uffemd for Side.If. 507 — FINAL PLUMBING
howevcm On building or improvement is Sold within one year of completion,On mamr-
Wilder will have the Wrier of pn ving mat W did not Wild or improve for purpose of
sale.).
❑ I,as owner of the pru,xa,am exclusively contracting with licensed Con...to
consuc el me pmjeci(Sea 7044,Business and Professions Code:)The Convmlors Li-
cense
i- pp 0r��y+a
c nse Law does not apply to an owner of property who Wilds or improves meson,and. �a Y w�n'�sl
who contracts for such projects with contractons)licensed pursuant to me Contracture V.+
License Law. oOsyL
❑I am exempt under Sec. .B&P C for this heaven �V .t A Z
Owner Data N 1 tY
WORKER'S COMPENSATION DECLARATION pp��//±'�
I hereby of ltd under penalty of perjury one of me allowing dcdandions: BY'L®ING
1 have and will maintain a Certificate of Consent o Self insure for Worker's Compen-
astion,as provided for by Section 3700 of the labor Code.for On,performanic of the
work for which Unix permit is issued
I have and will maintain Worker's Compensation Insurance.as required by Section
3700of the Labor Cole,for Unc performance of me work for which this permit is issued.
My Worker',Cnmpc ration Inst m tec[artier and Policy number are:
Carrier:5-r,4'I-rL Policy No.:7I 3Ca�UNf TGOO'f 0-P
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This axion need not be cnmplcled if tic permit is forone hundred dollarsolUd
of less.)
I eerily mal in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner sen a to become subject o the Workeri Compensstion
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:II,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code.You most
OZ forthwith comply with such provisions or this permit shall be deemed tricked.
z CONSTRUCTION LENDING AGENCY
�-r I hereby affirm that mere is a construction lending agency for the performance of
y' 7 the work for which his permit is issued(Sce.3097.Civ.C.)
W 25t<ndcr's Name
aZ ![Inn's Address
U J 0 1 unify Out I have read mea application and add,mw me above information is /
W (.. corcngcomactuComply
and With all
audband county nNinances and Stam tawsenter upon
QU WINlogenostrucllomerJ hereby aoWriamose,'. tires of miscioy mcnmr upon me
annvcmentionW property for Chad y an Purpose,'.
hs.
F G (We)ag. s save.inJemni(y and keep Wanless 1W City of Cupertino against
fq liahilitics,jwig nl1, o.`)�ndCx Uses 11M1 mayinanywayaccrucagainstsaid Goy
U z
me enc ofthc6 mmg of is mit. r O 1�
r4 APPI.I fed UNDE STAN AN 11.1,COMPLY WITH ALI,NON-POINT Issued by: Date 0
SOU U AT ONS.
N• .® Re-roofs
ignamr o t Ice for Dae
IIA%ARDOU ' ALS DISCLOSURE Type of Roof
Will me applicant nr futon building occupant store or handle homrJous material
a t e ed by the Cupertino Municipal Code.Chapter 9.12,and the Ilcalm and Safety
I
ode.section 25532(1)'! � All roofs shall be inspected prior to any roofing material being installed.
❑Ye:
Will me a l into nr future building
rat axe a ident or devices which If a roof is installed without first obtaining an inspection, I agree to remove
PP d by the 4uip
mit hazardous air contaminants ai defined by the Bay Arca Air Quality Managcmcnt all new materials for inspection.
istritl'! `—
❑Yes )INn
IhavcmcM1as Nnus\ma¢rial yuimmcnuunJcr Cbapmrb.95of me Calihm
I . .25533 anJ2553d.1 unJO.Ord ma if the building
i my res"mmifity to undly dmoecupanl of me
egal ix t ' r ivaaMcofacenificamodaCii"ney. Signature of Applicant Date
or authmised ager l DateAll roof coverings to be Class"B" or better