01120051 (2) CITY OF CUPERTINO
BUILDING DR9SI01il PERMIT CONTRACTOR INFORMATION_:
°0PERMIT NO.
1�1RED . FIR .CT CUPERTINO PLUMBING. 01120051
°"'i°l}234fE& NOELOKEEFE 10297 S DE ANZA BLV Ap'Y T/qT�!V 01
AL
)NE: (408) 253-0618 SANITARY NO. CONTROL NO.
o m z"ARCIiITECTl1iNG1•NEER:
BUILDING PERMIT INFO
O O BLDG ELECT PLUMB MECH
22= LICENSED I n CONTRACTOR'S DECLARATION pt' -
jz-e Iherebytiffian 0)ofthatIoreofthed,onerpradrafeofChapter.ra'ammemmml, COPPER REP IPE, � ATER
�. is in full Section Division Sof the BusinessnnJ m'ss o/ns Code.and my haenx FINAL
in full force anile 1.� H✓... S ED
i z < Liccns las LIc.H
f O a U Dom Cmmimn,r
a.O< ARCHITECT"S DECLARATIO.
I understand my plans shall be used as public records ( JAN 0 2 200`x,
;W —
1 u o O Licensed Professional
'~ZY
OWNER atIronBUILDER DECLARATION' BUILDING - Ss000
1 hereby affirm the 1 em exempt from the Cuno-ectorl Licenx hw for
Inc
—_a follow re (S iti 00315 eumessa Pmfe. i lih,ae Any
city
orcounty
u, wh ch q Permit. c t G alt improve,demolish,I ore.repair any structure
i3m pr ort t I. cy th ppl' i1f hpe nnfileas goad statement --
naine tip nut n p .otthec a u .uanxl�wlcnapmry y,RR9tQ•�Do333A,�®, „ Valuation
(commercial,nth Section 7000)of Division 3 of the us Bnes,and Professions Corte) , _ 1
or that the is exempt therefrom and the basis for the alleged exemption.Any vuthainin
„fSen1on70315byhryamicarth,rapermitaobjects,heapplicant I..civtlReadily 20,QP1`FNhThMFRFLOOR P UMB'ING Occupancy Type
'at hou nmme than five hundred dollars 1S500), Pane Y Yp -
❑i,a:o.•perof the pimparr.ormyemployees aah ager as their sale compensation. 301 - ROUGH PLUME GI .. .n ..
will do he vvmk:and the swcmrcis not,intended or offered for sale(Sec.'7fsw; ...
Business and Professions Code.The Comraaor's License Law does our apply to an, e
r
owner Ih
rof p,npeny Who buildsarimprmes mncar a ad x ba does such work lJmaelf 507 - FINAL PL INN
or through his own employee..provided that such vementemeins arc not ommndW of-
"offered ion,the. w howevere the building or improvement of grin is that within one;cnarwild of
icompletion,the ore owner builder will have the Horden of proving than the did not build or
mprove for purpose of vile.).
coLnsOwner ofthe p(Sec.7 am exclusivelycontracting with Werue contractors10 t
construct thedoes
project(Sec. (a a Business and Professions ills or The Convenor's
'a License Law docs nm apply man owner of property who builds or improves thereon,
'he
Co mel convects for such Projects.with a cammnor(s),IicenseJ Punuam to the
Cnnvanors Lice nseSec
'- ❑I am exempt under See. .°&P C for this reams - -
- Owner Date
WORKER'S COMPENSATION DECLARATION
I thereby affirm under penalty of perjury one of the following declarations:
I nave and will nmimain a Ccnlf,cam at Consent in vcll:i....a heir Worker,
. ;✓ Compen.mron, as provided for by Section 3700 or tire Lahr Cable, for the '
pmbarro en of rhe work Iia which this permit is issued -
❑I have and will maintain Worker's Compensation Insurance,as required by Section
371X0 of the L.1wr Coat,fm the Fair mance of the work for which his permit is -
issued My Worker s Compectorican Insurance r and Policy numbs are
Camicr- !fJ<-_GI(UI Policy OI ULy ... _ L.
CERTIFICATION OF CXEMPTIONFROM'WORKER., _
_- - COMPENSATION INSURANCE
-IThis,,ection need not b,completed if the permit is for one hundred dollars -
(EIOMor lass) .: . .— - i •. i . .
" I certify that in the perfornmr.e of the work for Oranrh s pemn('s i...ed 1 -
shall not employ any Person in any manner sr as to become subject to,the Workers
Compensation Laws of California.Dote
Applicant '
NOTICE 10 APPLICANT:If,after making this Ceni&ale of Exemption,you should
zbecome subject to the Workers Compensation provisions of the Labor Code,you must
Q Q fonhwilh comply with such provisions or this permit shall be deemed revoked.
rza .�.. '' CONSTRUCTION LENDING AGENCY ' '
- 1 hereby affirm that then,is a construction lending agency for the perlornaua
of rise work for which this permit is issued(Sec.31197.Civ:C.) -
,� Q Leader's Name - -
n7. z Lender's Address
U O 1 cenify that 1 barn read;his application cad sane that the above information is -
fa.Fa correct.1 agree ro comply with all dry and county ordinances and state laws mining
.Q U to building conswcrion,and hereby amhou.e representatives of this city to enter upon
y L] the vbuv ')it'r w to'ins,
property ria ify suit keep
purlases.
,e. S 1We)agme m.costs and exfy des is hi h may Mthe Cha of cupenino against
Vj liabilities,judgments,coos and i n of the which may in any way accrue against said
UZ City in quence of the graining of this Permit.
AP ' U )ERS %Y2S \\'ILL COMPLY WITH ALL NON-POINT
- so;:cEla1� �5U Issued by: r Date
Signatures Applicanl7Comr . Dam Re-roofs
HAZA OUs MAT IALS DISCLOSURE '
Will on,applicznt'or be mg occupant store or handle hvurdoos material Type of Roof - -- - .-
as defined by the Cupenina Municipal Code.Chapter 9.12and the Health and Safety , ..
Code.Section 255321.1' 1. • - 'f ,;
0Ycs _ All roofs shall be.inspected.prior to any roofing material being installed.Will line If a roof is installed without first obtaining an inspection;'I agree to.remove
�
i1 ha d s ' nm 1.as d fired by the Bay Area A Quality M eagcmcnt iari to all new materials for inspection. Applicant understands and will comply with
ovas No r M, all'noh-point source regulations.
1 have tread the hazard ns materialoccur
i remcnt. under Cb I 6.95 of the
California Health X Safety Code,Sections 25505.25533 and 25534,1 understand that
ifr does nm currently have a tenann that it is my reeponsibllity to notify the
an,of 1 rcqui cars ich muni be mel prior 10 issuance of a Cenificarn of
oaaa c: Signature of Applicant Date _
o F —'� IZ�3 Dot All roof coverings to be Class"B" or better
„j Own f amha rieed ape Daae
._.. ,.. :,. .. . ;,.. . .. . . , OFFICE