02050110 (2) CI BUBUILDING
ONUDPERNO
ILPERMIT INFORMATION:
FORMATION:
By'�BYDRMCASTLE DR ALL VALLEY PLUMBING PERMIT NO. 02050110
9wi Rte° NALBANT 170 BRANNON DR Aff�Ct�TYlY (ff2
•PHONE: (510) 376-4816 SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
a
BLDG ELECT PLUMB MECH
�y�
LICENSED CONTRACTOR'S DECLARATION RInh DD
o achyaRmthatlam,;fensdunderpmsP leofn,Code9(commencing WATER HEATER REYLA R
._C; w;m sec0on mmn)of Divkdnn3onW Bunln<an send arum:cion.cede,and any license
gmx� iadmn ror<e ana< F<_ r
=a rc a Licom Class Lie
O a, Dam 555___ Canaan.,
j 3 LL y A TECT'S DECLARA
t= ; 1 understane my plana shall be used as public records
uiy
i L c s Licensed Professional
OWNER-BUILDER DECLARATION
sear m to a 1 hereby affirm thin 1 am era t from the C.nunnm's License Law for the
C?a following reason.(Section 70315,Business and Pon essi.ns Code.Any city or county - $500
E F O which requires a permit to construct,aper,improve,demolish,or repair any structure
a3`-' poor mics isvmnce.alserequires theapplisime for such permit o file a signed statement ce
-- - --- - - -
Nm he is IittnsN puraimnl w the provisions of the Commnora Liana taw(Chapmr9
3(TAJR.CFIc8 ra6a Valuation
(commencing with Section 7")of Division 3 of the Business caul Professions Code) (- i �, I r` r \
or thin he is exempt mintfrounnd the basis far the alleged eimrptlbn.Any violation
of Section 7031.5 by any applicant for a pc mit suM1jens the applicant to a civil penalty
of not more than five hundred dollars J$500). 502APNhffiNA't PLUMBING ENERGYOccupancy Type
01,as a%net of the property,or my employees with wages as their whir cumpansmoo, 506 - GAS TEST
will do the work,and the strunum is not intended or offered for sale(see.7014, 501 - FINAL [[!!
Business and Professions Codc:The Contractor's License Law does not apply to an Inspections•
weer of property Who builds or improves thereon,and who does such work himself
0
or through bis own however,employees,the
provided that such improvements are not intended one
or _......
bffcice for axle.IC however,the M1uilJinimprovementis sold within ane Y
ennnpletion,the ownerM1ullder will have the heretics or proving that he did not bu Id n t '"
improve for purpose of sale.).
-01,tr r none property.am Business a d Professions
with licensede Comnters to -
_
construct the does
project(sec.7044,owner o and any w ions evlea The Contherco,
and
is
Law Jaen na apply man owner of a contr who builds en improves thereon, AUG
G 2 6 200ry-
t. .and,who contacts for such h Projccu with a conaonorls).licemed pursuant.in the. .. .. ... _ . U G U L C _. _... _ ._.._....._.... .. ......_._....
01 tans sire d unde Law.
❑lam cxcmet under Sec. � s.BkPCfor this re
Dwnrn BUILDING
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty or perjury one of,the following declarations
e1 ❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Cade, for the
p<rf.mta rea of the work for which this permit is issued.
01 have•end will maintain Worker's Cumpenselion Immunes,as required by Section
37W of the Labor Code,for the pcoformaned of the work to,,which this pmmit is
" issued.M Worker's Compensation Insurance eani/e(Jend Policy7ny`tu/bet -
Csrricr:'e .. C.I `.f P.hcy No.a L7 //f�
'" C[RTIFICA ION OF EXEMPTION FROMWORKERS';n i
COMPENSATION INSURANCE' '.
ITh dxbton need not W mmpldcJ if the permit ns for one hurdted dollar t s it t
($1 00)or loo.) _
"1 certify that in the Pe in ad,nce.f the work for . ch tit s Poem t e Warred;1
.shallanal n sum.employLass, anon in any manner so as'.bdomc sob3m to the WorAera'
Compcmation Incas of Califomia.Dam. `
Applicant '
NO"rICETO APPLeWork If,Compensation
this Oisiorcate s of the Labor orioCode.
youshould •'
Wconiehcomply
osubject y the such Workers
s ons or this p Permit shall be deemed revoked u must
rovision
0 O forthwith Com 1 with such
F;i .CONSTRUCTION LENDING AGENCY
y 1 hereby firm that there t construction leading agency fortit p for nonce
of N a ark for which this permit is n,iiad(Sec 3U97 Ci.C.)
LendName a ..__ . ._... .._.. _. . .._. -_. .. _.. .. ..
Lend Address i ..
V'Q Icenify thmlhave reed thin application.nd stare that the.b...information in r
W La correct:1 agree to comply with all city and county ordinance and state laws relating
O.r, to building construction,and hereby autnoim moresenediras of this city to enter upon
ythe above-mentioned property for inspection purposes.
(We) give to nave!indemnify and keep harmless the City of Cupertino against
F to s liabilities,judgments,costs and expenses which may in any way accrue igninsr said
C.3 Z City in orwequerme of the granting of this permit. \l (�
APPLICANTU L ERS 'DSA\ LCOMPLY WITH ALL\'ON PO IST Issued by: Date it
Signaturpian ontmao au Re-TOOfS
HAZARDOUS MATERIALS DISCLOSURE
W 11 the pdica t f t W 1 g acupi m store or h iMle hauNous material Type of Roof
as d pi ed by,th Cupau roM n ip Cod Chapter 912,and h Health and Safety _
Code Section 255321 1 i 1 3
DY ) _All,roofs,shall be-inspected prior to-any.roofing material being installed.Will[he pplicantorInas Wil geacc p re ,equipment deviceswhich If a roof Is installed without first obtaining an inspection, I agree to remove
amt ht"an u'ar c.ntammants is dby the Bay Area A' Quality Management
District? all new materials for inspection. Applicant understands and will comply with
I`I
all non-point source regulations, - -
R1y I hove,cad the laidSafety
Core. maims 2 mgm 25533 notice Chapter 6.9�Xeram nd rite
Califomia filing
dos SePoty Code Sections 25505;25533 and 25534.I understand the
if 0e buildI dos requiremnot ents
w Wive"tenant,tem it is myresponsibilityoi,a.Ca notifytheof
ocEupam of the requirements which must be,met m issuance ofte Cenifcate of
Signature of Applicant Date
owns in rathimimcl.gcm .. - Data ... All roof coverings to be Class"B" or better
. OFFICE - .. . . _. . . ..._.... .