02100056 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BuIL118G"TrPJXE5NEWSOM AVE MIKE COUNCIL PLUMBING INC PERmirN(02100056
QWffPkW49srBUELL 1977 O ' TOOL AVE APPLICATITVV "TY2002
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41 ZONE: (408) 272-4900 SANITARY NO. // ��++ // CONTROL NO.
ARCHYPEC IENIINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION p}�p
<°u 1 hereby allirm that 1 am licensed under provisions of Chapter 9 buided racing RE P I PE (HOT & J�b?I 5�ription
w with Section?(XX))Ol Divesne3ntthc Basu ss and Prefie ora Codc,und my license",
t7, in full Inde nn tt
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F—O� OWNER-BUILDER DECLARATION ��/�
oea foll1 hereby allirm'hal 1 am exempt from the Contractors License Law home ��f�D' M®O 0 O
to_p O owing mann.(Sccdon 7031.5.Busess inand Pinkstone;Code:Any city orcounty 4'�
which dyes uira Pmit
erIn construct.alter,improve.demolish,or repair any strecture
nt''^
prior it)its issuance.also m9uires the applicant forsuch permit o file a signedsutemem
`- < that kishsansedpursuant tritbcpmvimunsorthmContractoraLicense law(cnapter9 3Sd159.9 6A10A Valuation
c'M (commencing with Section 70XXB of Division 3 of the Business and Prodcaions Ceeq or
a 3$ turn'he is caempl therefrom and me hosts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjeces dm applicant to a civil penalty of Z JXPls4`N6hW9HFJJ`J`JROccupancy Type
not more than five hundred dollars($500). 301 - ROUGH PLUMBI G
L u owner of the property,or my employees with wages as their sole compensation.
will do the work,and Ne swctum isnot intended or offered for sale(Sec.7MJ.Business ¢sky M
and Professions Cute:The Contractor's License law docs not apply to an owner of 507 5"2 - F INAL Ltd l°t ftCcuons
properly who builds or improves demon,and who doossuch work himself or'Bough his
Own employees,provided that such improvements am not intended homebred for sale.If,
however,the building or improvement is sold within one year of completion,Be owner
builder will have the burden or proving that he did not build or improve for factorial of
sale.).
Q I,as owner of the proPer'y,am exclusively contracting with licensed conowtorx In
construct the project(Sec.7044,Business and Professions Chided The Contractor's Li-
cense Law docs not apply to an Owner of property who builds or improves Hereon,and
who contraci for such projects with a con vial r(s)licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. .B&P C far this headed
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby amen under Penalty of perjury one of We following declarations:
I have and will maintain a Certificate of Consent to self-insure far Worlar i Comfen
sa'ion,ss Provided for by Section 371X1 of'he labor Code,for the radm reake Of the
work fur which this pednd is issued.
❑1 have and will maintain Worker's Compensation Insurance,as reyvimd by Section
370(1 of We labor Chile,for dal pertmmaces Of the work for which this permit is issued.
My Workc's Cyyrr111
ms,p��c��na((��Yt'ytipn lnsumnc ca er and Policyn cr. r.
C i {�y1p�PoliNY Ni
CERT ATE OF %E Pf10N OM WORKERS' -
COMPENSA ONINSURANCE
(This section need net lac completed if the Permit is for one hundred dollars P$100)
Iccc)
1 certify that in the pertarmance of the work for which this permil is issued,1 shall net
employ any".,a in any manner.at as to hecome subject n the WorkersCompensation
Laws of C.14 ma,DateApplicant
NOTICE TO APPLICANT:IL after making this Cenificall of Exemption,you should
become subject to the Worker:,CemIsdain ion provisions of the La or CnJe,you mux'
O O forthwith comply with such provisions or this permit shall he Deemed dvoked.
z CONSTRUCTION LENDING AGENCY
[-. 'N—� I he allay allirm that there is a conslmction lending agency or the pmfrmarnce of
J:4 > the work ler which this permit is issued(Sce.3097,Civ.C.)
W 0 Under's Name
a. Lender's Address
U 0 1 certify that 1 have mad this application and stale that the ahuvc information is
F codec'.I agree to comply with all city and county Ordinances and state laws relining us
0 U building construction.and hereby authorise representatives of this city to enter upon the
} W above-mentioned property for inspection purposes.
(We)agree ht save,indemnify and keep harmless the City of Cupertino against
G buff hit.,juJ t culls and"Per"m
x r swhic accrvce t said F" tin green.. pe :c .n cony war srn'na vi y
U z inrR consequence of the granting of his fermi
N]]''UNDER NDS AND W L CO PLY WITH ALL NON-POIN 1 Issued by: Dale'U, TIORe-roofs
f Applin m,vo 'mom 'nIIA'/,ARDOUS MATERIALS DISCLOSURE Type of Roof
ll the afplicam nr lumrc ha"lti"ng tkcupam store nr handle haraNnua material
by the Coercion Municipal CnJe.Chapter 9.12,and the Health and Safety
on 2553xfa)7 All roofs shall be inspected prior to any roofing material being installed.
eau mea licanl or future buildin nt ate a ment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
Pp 8wcupa yuifdnus air conmminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Distrct? 1
❑Yea
HowereaJdralemrd"a materials teyui025T
tier Chap'cr6.95ofthe Califw
niallealth&Safety Chale., m 25415,25531 .1uMcmunJ thatiDM Wilding
Jens no'em entlphase a tewa, t is my ti 'y to noddy theoocupan'of the
recommit, iswhich mum me tont nissuanOf
care of Elame Signature of Applicant Date
s All roof coverings to be Class"B" or better
OwnerntWill riri,cd agent