02030043 (2) CITY
DPERONo
NPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
19409 PHIL LANE 02030043
OWNER'S NAME: APPLICATION SUB DATE
JAMES CHEN 03/11/2002
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
u BLDG ELECT PLUMB MECH
LJ L__I
LICdad
m i firm th SED CONTRACTOR'S DECLARATION Job Description
i z_ 1 hereby affirm that 1 am licensed undo 'elision. f Chapter 9lcomntencing
„ withScaion]OW)ofDirision3ofthcBuS'ny�ndProf�yya Cnandmylianu REPLACE SEWER LINE .
u m mil ftanme an¢err t. Je `(��
Late t�hss S Lat: _
D Conv or
o a v R shill T'S D LAR TION
I undersmnJ my plum shall be use m public records
T
3 i p O Limned Prof W.mil
c ei OWNER-BUILDER DECLARATION
Lair r51 hereby affirm that I am exempt from the Contractor's License Law for the
t 3following reason.(Section 703 1.3.Business and Professions Code:Any city or county $1950
Q which recut ns a permit to construct,alter,imprmc,denml lsh,or repair any suucmrt
a. that
t I q thppfc mfor such penniuo Ble nsigned smnemem. ..... _. .. __. __ __
(horn licensed gwith e ti n theprovisionsn3of ofth ButtresLlcenseLawonsCoer9 ��, �,>tir3�_s,�'a��i,'��T'�5�;�a1, -�,6 Valuation
(commencing with t to
of ON onlof the Businessand se Law ons Cade ;1 t h (OM1,
t that he ni exempt thcre(rom and the boos for the alleged exempt on.Any v ola on
-of Section 7031.5 by any opplicism for a Fermi,subject,the applicant to a civil penalty
'of not mom limo fire hundred dollar,(s500). joel?Nli'� R & WATE Occupancy Type
°1,as viva t of the propcny,m my employees wen wages as their sale compensation.
,,ill'do'the work,and the rtmcmre is nut'intendeJor offered for'sale'ses:7044, - - -
Bualois.and Prare...ion.Cade:Flat Counselors License Law does not apply to an 3 01 - ROUGH PI WjBgIlNGpections
..a, property was Wilda or improves thereon.a ad vs In does souls.ark himself 507 — FINAL PLUMBING _
or thrdugM1 is awn employees.provided that such improvements are not intended or _ _ _ _ ---' _ _ _-"
o
ff red fotrst le IL how the n Id" g p t sold 1h Y r of -- - -
completion,the owner builder will h ah burden f P g th t n did n ,Wild or , v
prove for puryose of. I ) 1
ownern n contracting t « contractors a
uto nth project IS 704 B J Professions CW 7 TheC t crs LicenseLaw does not viF1 to v(p property Fla ba F thereon,
e_ n mmbfor n P 1 nalac n cms).ic'mealP rsunm.tne ---
Contractorsitio
License
ID I annexempt Sec. B&P C for ma
�.
—t-
,
._.
. .-_
V�
Own
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of Mrjy,vile of the following dcclaralmr,:
A ❑ I have and will maintain a Certificate of Consent to self-insu a for Worker's
Compensation, as provided-far iby Section 37W of the Labor Code, for the
performance of the work lot which this permit is issued.
°1 have and will ntainihin Worker's Compcnsauon Insurance,as required by Section
3700 of the Labor CWe forshe perf(mance of the work farwhich this perm t is
i sued MyWW k sCo t nI . more tamer nd Pal cy nM e "
t� 4eYi1 � . _..
'dmf t / 'Policy l�'o�,14-/9 �
:CERTIFICATION OF EKEM N FROM 'ORKERS'f 1 A7 to 5.1. i.1.w :\t ;l.e 1• i i a..
(Thos uctmn_ COM Pr NSA T1 ON INSURANCE ` - ._ ___
.. f. .. ..-_,.__..._._..-. ,.___ .-- ------ - __....._ ...... _.._. _- -..
- ted not be mmplited if the pcnmus for are hundred dollars '" '`" is
ISI00)or less.)
'i I 'ndytl t Ru,wa n 1 c ft k'for which ubjctI n issued, �
shill not employ,any pc son m any manner zo u to become subject m the Workers
Compensation laws of Califomia.DriteApplicant
-
i NOTICE TO APPLICANT:If,after mak ,i Certificate
making s Ccnificare of Exemption,you should
Q ^
Forthwith must
O "no:� ked. _ . .
become uhf«n t the Workers Compensation p s of the Labor Cad you mu
comply the such ns rah pe t shall be d< d
+ i hath RUCr1oN LENDING AGENCY "
f' Ila- by hick th n th construction leading agency f the p f once '
of n - k f which th s pe n ." d(S a}p9)C C.1
Lenders Nam<-. - - •: . . — � • a _ ___ .._. ....__ .. _
Q
Lc der',Address" '
I tinily that l Wee real this application and state that the above intimation is
cowed.l agree to comply with oil city and county ordinances and state laws relating
0 U to building construction:and hereby authorize representatives of this city m enter upon
>1: Jhe ubirvommtaioned pr.,cn,for inspection purposes.
�.gk, (We)ago.tosdvc,indemnify and keep harmless'thi City of Cupertino against
lO liabilities.judgments,costs and expenses whichmay in any way accrue against said
.0 Z, C'y at consequence of the griming of this pcmat. n �
URC UNDERO SNDS'AND WILLCOMPLYWRHALUNION'-POI ", ISSIICd by: i DflIB ll
if
S- atract., ate ;., Re-roofs
.�. HAZARDOUS NIATERIALS DISCLOSURE
Will the applicant rfranc bu Idng acen,ain ,are o'handle ham Niu:mate"1 Type of Roof .. .. ...... .-:. _ ._. ..
. . ds defined by the Catarina M n c pal Core.Chapter 9.12.and the Health ad Saf ry
Code section 2553211a1 t t',, (. ! ! •1 e '� y,l i t 'S:
Allroofs_shall be,mspec[ed poor to any roofing material being,mstalled_,
Will firapplicantorfuture building occp t use equipment or devices s`which If a roof is installed without first obtaining an inspection, I agree.to remove
emit h Nous air conn m pant.as defined by the Bay Area A' Quality Matngiment
Distract+ all new materials for inspection. Applicant understands and will comply with
f. °Ya_al • ' a all non-point source regulations.,.,
`�. I h d the Itivd as materials rtgmrcmcnts under.Cbaptd 6.95 oCthc
Califomia Health&Safcy Codi.Sections 25505;25533 and 25534.1 undcrsund that
- Hite building does not currently have.anion.that it is my responsibilityto notifythe' -
. f t of m quire est'which nest he t prior t ikma c f Ccnific2,lhe "
Ce• •_ t \ Signature of f Applicant _ Date
All roof coverings to be Class "B" or better
iare
OFFICE _ .. ... _