01070047 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22641 SAN JUAN RD CUPERTINO PLUMBING 01070047
OWNER'S NAME APPLIC TION SUB DATE
WADE JOHN L TRUSTEE 10297 S DE ANZA BLV 07,12/2001
PHONE: (408) 283-0618 SANITARY NO. CONTROL NO.
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s z ARCHITEC(ENGINEER: BUILDIN PERMIT IN
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z H_ LICENSED CONTRACTOR'S DECLARATION Job Description ell I
o� o, hcrebyaffmthalamlicenscdunderprovisionsofChapmr9(commencing COPPER REPIPE.
w,m Sedan 7" 'Divumn 3 al the Business nnd.Professions Code,and my license
6 $ is m Poll fovea pO
leo Li ensu Class _ Lic. _I FINALE®
O a.U Dam SDECLAr
3 w 11 w1 ARCH ll be. DECLARATI N
h"LLvQ�to
O Q 1 unslersmnd Iny pLms shall be useJ as public records AUG 2 8 2001
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H
S p Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 lin exempt from the Contractors License sew for He I BUILDING$fj Q Q 0
1-z a' following rcasna.(Section 7031.5,Business and Professions Cade:Any city or county
4 C which q permit o construct.alter. p demolish. p tu
y strucre
w .pdo tow I req the ppl ra t f xh pemuu fI gned va¢rrcm _ _-.. _-__.
e3 (hat he I,licensedpr_ar .total posi,ion, the Contractors L' to (Chapter9 Valuation
formporicing-w ithe i-.7000)of Division l ofdrB mep end Prof< ns Cale) ice,�i "•y'�!3 8'1'7,( �{"®n4a� S1 `a i il.J:k: t
or that be is exempt thcmfrom and the basis for the alleged eaemptloiiAny violation
of Section 9031.5 by any applicant for a Permit subjects the applicant m a civil penalty
of not more than five hundred dollars(S5oo1. 2024PNbffl!�BRFLOOR PL BING'" Occupancy Type
111,as owner of the propcny.o my employee with wages as their sole compensation, — I
-wilt do the work,and the structure is my,intended or offered for sale(See.rose, 502 — FINAL P]litJ41 '1KGs�NBRGY '
Rusincss and Professions Coda.The Convaaor's License Law does not apply m an
owns,of pmpeny Who builds or improves Ihcreon,and who does such work himself 507 - FINAL PLUMBING
m through his own employees.provided that such improvements am not intended or
offered far sdlf If,hostwer,the Wildin - improvement Is sold within ane ear of
garurden of pas y
completion.Me owner-builder will have the burden of proving that he did not buil)or
Improve for puryose of salc.l. t
con asowner ofthe pvpeny,ame usinessacantmmingwithlicensed CQmemnao I . ... -o .
_ awd the project(Sec.)to a owner o and Polsny w ions Cod,:)The Co then'.
License law dors not apply m an owner of progeny who build.uor eLpanvea Hereon,
f and.who contracts.for such_Prnlens.wiM a.conmxm,ls)IicensW.pursuant.to.tbe
Contractor License Law
01.. .
sm czemptuMer Ste. '� � t' s �B&PCfm this rennin
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hemby affirm undo penalty of perjury One of the following declarations:
❑ 1 have'and will maintain a Certificate of Consent m self insure for Worker's
_ Compensation,to provided for by Section 37W of the "We Code. for the
performance of the work for which this permit is issued .
a and will commum Worker's Compemmion hicumnss,as required by Section
01e,7110 o"the Labor Code,for the performance of the work for which this permit is
issue 4 Y IVorkee,Comps satmn ln:umnce ca ' dPol y number are
.. .. - /rya{I.�1^
ft Puh YN VS/�J�Il •.s.' 1 t t .,a fl y I .. `_ _- __._... ..
RTIFICATION OF EXEMPTION MOM WORKS
'�� COMPENSATION INSURANCE
ung(` od not be,completed Iran permit is for ane hundred dollars
ISI WIs.I
•I certify that in the performance of the work for which this permit is issued l t. _ "t^: P' -
xti511 not employ xny person in any manner ad aa,u,bemnm subjett m the WorkerC
Compcnsation Lawa o alifornia.Dam
'
.
Applicant. _t K
NOTICETOAPPLICANI':1L alcor making this"
his Cerlilir m off Encmptiun.you should
Q Obecome subject to the W'orke/s Cnmpedsbtiari provisions of the Labor Code,you must
forthwith comply with such provisions or this pcnnit shall he doomed revoked
Z ':CONSTRUCTIONLFNDINGAGENCY
a:> Ihsreby afloo,h,them Nacaotow,un lading,va,lbr Heperformmnce
of the work for which His permit is issued(Sce.3097,Ci¢C:I
Q Lender's Name. •- .•. _
4' Lender's Address ' '
U I certify that I have read this application and sonic that the above information
is
Lr. f, emiect.I agree to comply with all city and county ordinances and state laws relating'.
0:E)
to building construction,and hereby authorize representatives of His city to enter upon
;s, W the above-mentioned property for inspection purposes. -,
E„ p, (Visitagree to sa indemnify ndk ph 1 ache city fC pen'nail
VI
lialadilies,judgments,c t loparses a hich may in;nY way seems against laid
UZ Cn fohe Join,'o1M p 't
SI LICA NSTSAND WILL COMPLY N'ITH ALLr�NON POLYP [SSUed by: Date 4 (J
2 Q
Signature at Applic. UContractr t '., pate Re-roofs
k AZARDO S MATERIALS DISCLOSURE
Wtn Me ppbra r Pom wnatn,x cupant t dt na
or wn :,nmaa mat I' ..Type of Roof
.asd fn JbY @eC petno anteral Code Chapter 912.and the Health and Safetyi1 .,,1.j
Cad S❑t 2553'_
(al �N ., i f. . s. t.
_ _ .All roofs.shall be inspected prior to.any roofing material.being installed. _
. Will the applicant orfuture building occupntuse equipment ordevices which If a roof is insmlfed without first obtaining an inspectioli'"I agred.to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
Diamer all new materials for inspection.-Applicant understands and.wlll comply with
J °Yea ONO - - - all non-point source regulations,,, _
1 have read the hamNnus materials requirementsunder Chapter 695 of the
California Health A Safely Cade.Sections 25505.35533 and 25534.1 understand Mat
if Me building does nm carnally have a amort.than his my responsibility m ratify ahs.
ecu am of a requirci nis whi h must be met prior m ill...ee of a Cenificam of
., 0 ..
Signature of Applicant _._ _ D'ate .
ownm ar aama tea agega, Dam All roof coverings to be Class "B" or better
:.
OFFICE .