00120043 (2) CITY OF CUPERTINO
nun.DING DIVISION PERMIT CONTRACTOR INFORMATION:
' BUILDING ADDRESS PERMIT NO.
10355 PRUNE TREE LA BUDGET PLUMBING 00120043
OWNER'S NAME: APPI.ICA'r10N SIDE DA'1'17
10 GIoll ELFTERIOS P AND CATHE 2869..5 ROANOKE ST 1.2/06/2000
HONE: SANITARY NO, - CONT ROI.NO.
(510) 303-7847
�00r,i,hSccti,m700OOr1
l'IHNGINI!I!R: ❑UILDINfi YERhII'1'INFO
W— BLDG ELECT PLUME MI7CH
to j w
melts
Z z v=im.Seby acON
fim'that I am enssedi under S DI ions(Chap 9(commencing Job Description
°Zt—� Divir,ma 3 ofthe,9u%ineo and Pmfccsion.Cdc.and my license
V_
a---
is thou a,ree and elrat.
zS I.iccn>c Cla" LIc.p
°m� Dam Cnnnacror
waa.' ARCHIIECr'SDECLARAIION WATER HEATE RREPLACEMENT '
F•a H 1 un le"wrid is pito.hal l M mcJ a.Public mens,
ce
ce}E
e p z Licensed Professional
_ OWNER-HUILDER DECLARN'ION
1 hereby oRlnn that I.,it eampt from the Corld car's License Luw for the
C Z< following rearm.(Section 7031.5.Results%and Professions Code:Any city or county.
SO which fuquhr,,pen.ills......incl.aIle,imptme.denolieh.of'rvPair any ntmetu re
i3� prior to it,i...twe.a]...reduim.Nhe applicant lit,such permiuo li It,a signed vlaera'd
that he is tuned pursuant to the pnm-i.uons of the Cuntmchers License Law lCM1apua 9 Sy. Ft. Floor Area Valuation
(comnenemg with Settled 700(0 of Divi cion J of the Rusial and Profeasinm Code)
or that Iw is exempt th.refo and the baric lie the alleged cscmpdoo Any ululation
of Section 7031.5 by any applicant for a permit ib"O.,the applicant to it civil Iendt,
,if net mnrethan five handled dollars a5atn. APN Number _ OccuphatoyTppe
❑I,as(loner..aha noperty...r Illy ennployceN with wages as their ole compemation.
will do the k and the structure is not intended or eficrod lot sale(Sec.794.
Had . d P ler,nn,crde lee Cnmmada'License Law does t appy to an 316,3037. )Required Inspections
or of property Who builds or innp rues shern,and who ds such work himself
r rodoes
his own employers,provided that such innproven Gals are not intended nr
offered for%ale.If however,the building or improvemmat is,add within one year of
notnplesion,the owner builder will have the burden of proving amt he did not build or 502 — FINAL PLUMBING ENERGY
nprn,e for pnmmNe mrwle.). 506 — GAS TEST '
171.uN,w m of the In'olel,,;m...lu.ively a n ecting will,Iicumul....ina,l ,,
mtr;,cl no, .jet,(ice.7(1,14.Han ,ma r�..res .CodvO) Lie C....ral 507 — FINAL PLUMBING
License Law Jae.no.,ply,o an ower of Pmi Who build,,,,,improve,therown, '-
Co who ,meets lin weM1 prnjens with a commnorly licensed pursuant m the
.aid his c LoIc"Ic Law.
❑I am.xempt coal .Ii h l•C to,do—cawan
Owner Ila[.
WORKER'S under maltyCOMof
on DECLARXI[ON
hefalloing VX
I hereby mtinn under Penalty of perjury one of the following Jcclarminnz:
Cl I have and will maintain it Certificate of Cometh to.dl-insure for Worker's V/
C..nnpen,alion. as pmvidcd f..r by Sce[iva 37N) of the I,nbnr Code, for the
peffanamce of the work for which this crant i.issued.
❑1 have ad will maintain Worker's Compensation Insurance,as required by Sermon
17,1 of the Labor Coda for the pudi,mtuncn of the work liar which this comit is
wed.My Winkel Comlernmion Inmrmce carrier and Policy numher are:
Camey: Policy No:
CCIt'fI171CATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibiv,action need not be completed if the pemnit is for one hundred dollars
($100)or less.)
1 verify than in the perfortmeal of the work ter which[his Permit is iv%ae.I
shall not employ any person in any manner w as run become subject In,the Workers' .
Connpenmtion Laws of California,Date
Applicum
N(yfICE'bjectt'Ite Work IL after making
npa Cedil of ofliaemptiodyou.hould
st
becomesubjectcomp y the Worker's Compensation provisions of a dhbor CMe,you muss
Q O lonhwith comply with such proviuinm or this permit.hall be deenad revels.
I
,^r h CO.RanUs a oN LENDING AGENCY
' 1lurchl alliin this theniss consmsnte Iendlnp,C.) for the Ierli,rmamc
of the work for which Ilii«mnit i.issued(Sw.1(197,Civ.C.I
Q Ledre Ander'% d
7 z Ln's JJreenJxN
C.7 C I aenify Ihu[I have mad his application and sidled.,the alxsve information is
4asc mu
eet.I agree ,cmnply with ab city and county'on inansem
ees and laws relating
Q V tohuili ia,,or,fuctinn,and hcmby owhari'rc rcprocnmfou%til thin city m enter upon
} Li: the al.n'omentioned popery for impection purpose..
F a (W[)most,it)wee.indemnify and keep hamdtssthe City ofCupertino against
'
fG liahilities,judgments,costs and expenses which may in any way accrue ugaina said
C) '� City in uu,..Iwn.a ol'the granting of Ilio,nous.
APPLICANT UNDERSTANDS AND WILL COMPLY WDII ALL NONdbIN't' Issued by: Date
SOURCE REGULATIONS, y'
Signor,of ApphcnNC..nraemr Dai Re-roofs
I IAZARDOUS MAI HRIALS IASCLOSUIll7
wd1 me applicant m rowre Melding occe cam sae or hmwHe hamNovs nate ild Type of Roof
.is defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
Code,Senium 25532(.)7
LD yes C1No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building rccupam use equipment or device which If a roof is installed without first obtaining an inspection, I agree to remove
nit huvaM..uv aur conaminam.ar defined by the Huy Area Air Quality Managenant
isu;et! all new materials for inspection. Applicant understands and will comply with
❑Yes 0N all non-point source regulations.
I have mad[he harardnuN materiub requiremmnte under Chapter 6.95 of the
CaliL,fnia IIcah,N sanity Curie.Sscdons 255115,25513 and 25534.1 c I...mmi[hut
if the holding doe%not currently have a'court.that It is my responsibility to n..tuy the
.apart of the requievall s which must Ac met prior to issuance of a Ceelfiaam of
Occuponi Signature of Applicant Date
owae,n,aathnri.edagea, Dave All roof coverings to be Class "B" or better
OFFICE