00080133 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMITNO.
OWNER' ' 'EATERS MP LA0081711 7-s
S NAI10/+10 NORWICH AV WATERIUST APPLICATION SUB DAIL
sopNI:: BIELEFELD JOHN J AND PRISCILLH I /p4 — AVE
, snurrnxr Nd. CONTROh Nu.
0 O O ARCHI'IECOENGINEER: (bio) — BUILDING PERMIT INFO
uC BLD( ELECT' PLUMB NIECH
H2W I=1 LI IJ I-J
%Sh 1.ICENSI:D CONTRACTOR'S DI-CLARM ION
Job Description
O%—w 1 hc..by affirm unit 1 an,licensed toad........ ion o1'Chnfer 9(commencing
F.,v,_eu with Section 71X)(110(Division Sof the Rueinesssnd Professions CW,and my license 1
3 iamrmnkrree. our
Zy 2k
zt License Class Lie.I
110
ce 11 Date tt( 1! 1 01) Co.nm[tnr WATER HEATER
u \RC IIII'[e used
DECLARATION
— ; I uuMnnmJ my plans shall be acted ux puMlc rcmnLv �(/f
d C Gp�O Licensed Professional /
e• OWNER-BUILDER DECLARATION �Il
I hemhy affirm that I nn caempt fines the Contractor'.License Law ref the
following seem lSectinn]031 S.Business and Professions CWe:Any city or,county
I O which I P rt e I r it P d h p' y,m entre
a3� Prot t I- I pl
ef
Ih ' l' ' If "h Pe 'tl 11 t b J.tntcn
- nitlh II t dhe prawollon,0t iC unriLicense 1aw,ICION,r1) / Sq. Ft. Floor Area Valuation
(communing with Scenes 7000)of Division 3 of l@business and l ftso :Code)
m thin he is exempt theredom and the basis for the alleged a®mptimi Any violation
of Section 7031.5 by any npplient,for a permit od jems the aPplicam to a civil penalty
ofnotnorm than five hundred dnnar.(1500). APN Number Occupani,nFRIPYe
D I.its ownerof the ao,erty.ornny cmpwyces with wages as their sole mmpensution.
will do ate wore.and rhe.tracome is no Imendeit or attract for.we(Sec.7u4' 31691.
Business and Professions Curie: am Connector,License Law,does rol np,I,matt Dircd Inspections
owner of property Who builds or improves imman,and who does such work himself
or through his own emploi pro.ided but such improvements arc not intended or
offered for sale.IL however,the building or improvement is sold within one year o1 502 — FINAL PLUMBING ENERGY
impletion,the sinner-builder will have the burden of proving the he did not build oar
improve for porp...eof.ala,. 506 — GAS TEST
Cl 1,as ownn of he po,d ,am cxclivi,d, unlowing I"It licensed cnmmctr},or 507 — FINAL PLUMBING
oeameed the pupae(Secs AWt.lousiness and Is 1—fon,Coale)The Cmumeco,.
License Low does not apply to an owner of pmpeny who builds or improve thereon,
and who commas for such projects with a contmcings)licensed pursuant to the
Comment's License Law.
Cl 1 um exempt under Sec. .B.F 11 C for this reason -
Owner Date
WORKER'S COMPENSATION DECLARATION -
I Mmby affum under penalty of perjury one of the following declarations:
1 have and will mninmin a Certificate of Consent nn self insure for Worker's
mnpansatirn, a, provided for by Section 3700 of the Lnhor Code, for the
perlisnnumcot the work or which this permit Is hired.
D 1 hive and will maintain Worker's Compensation Insurance.to,rectums by Section
37W of the Labor Civic,for the performance of the work for which this p.if,is
issuedb Worm-Compenxulion Insurance carrier and Poly number are:
earriTwL gory PaheyNn,fXJKfu 0 01
CP,IfI'I IICA'IION OF EXEMI11'ION FROM WORKERS"
COMPENSATION INSURAN'C12
(otis section need not be completed if the pennil is for one hundred dollars
IS 100)or Ie.s.) -
I sen it'y that in the perfbrm:mce of the wink rot which this remit is issued,I
shall n I enpiny.any pawn in any earn oar so as u,become nah,l Io the Worker,'
Crn.pcnsmion Laws or Culilbrnia.Dale
Applicant
NOnCETO APPLICANT:If,after making this CeniGcme of Exemption,you should
become subject to the Worker's Compensation provisions of the Lams CWe,you must
Q forthwith comply with such provisim,orthis Permit.hall be deemed revoked.
FZ^' tiCONS T RUC"I'ION I.FN01 NO AG ENCY
ai1 herehy aft!mt Oral fine is n eonstmaion Icnding ngcncy ho de,Pcifm,nenec
[77 Of the wad If,which Ihix permit is issued(Sec.3097,Ci,C.)
S Q Lender's Name
= 7 LcnJe:.Address
V 1 certify that 1 have rend this application and van,that the a ave infomtmlon is
�+ F comet.I agree to comply with all city and enunty and cam,and son laws miming
O U o-,bllding nrtom ceam and hereby rmnndc
xereir ..amor--this ail,10 erne..pan
} ryt the abme.nmmianet property lir inspection pa,r co
lwe)agree to ave.indemnify and keep harndcss the City of Cupertino against
Zn liabilities.)udgmenu,coasts and espenes which may in any veny secure agaimt said
f„) Z City in consequence of the Granting of this pemm. 1/ 1
^ APPLICANTUNDERSTAI USgND WILL COMPLY WITH AEI.NONPoINT ISSnfd by: ` Da
lot"',REG L TIONS 0, (Q -(4/-
Sinai
, ( T't(AI—
Sigaiii ic unnncm. rate
Re-fools
]AROOUS
MARIALS DISCLOSURE
Will the applicant or fature building occipital once or handle hamNous material Type of Roof
as defined by the CuPenino Municipal Code,Chapter 9.12,and the Ilealth and Safety
CWe,Section 25532(0)7 Cl No
Cl Yc' All roofs shall be inspected prior to any roofing material being installed.
w111denpp.ieamorlmmebnudingnceaphmuse tHtdpntrcntoraevlacawhich If a roof is installed without first obtaining an inspection, 1 agree to remove
,.it huz:mlous air Concmrima is as defined by me Bay Arca Air Vnaldy Managencm
District] all new materials for inspection. Applicant understands and will comply with
O Yea ON. all non-point source regulations.
1 have mad the h:vsdor,materials mipnirements under Chapter 6,95 of the
California Health&Safety Code,Sections 25505,25533;md 25534.1 undcrsmnd that
ly the builAing derma orient,coeammtm,that h is my msp.n,ihilitymnul'ny0m
'ncupam of the re4uire Int, 'hie nms'I M,tel prior In iosuunm of a Ccrtifieatn nl
rramey'� I -/-4-Y-1� Signature of Applicant Date
mess r,amoriad gent Dote All roof coverings to be Class "B" or better