02080013 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT SrCONTRAC.T,OR INFORMATION
BUILDING ADDRESS: PERMIT NO.
22451 ST ANDREWS AV WATER QUALITY PLUMBING 02080013
p.y(y $, �I�, � APPLICATION SUB DA'I'S
liKliNA1HE�M 1860 ALMADEN RD 08/05/2002
SANITARY NO. CONTROL NO.
PHONE: (408) 267-9330
ARCHITECT/HNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MFCH
5 i LICENSED CONTRACTOR'S DECLARATION Job Description
OZE,O Ihereby aBJrmmatwanlicensed and previ.sionsofChapter 9(commencing COPPER REPIPE/MAIN LINE
with Second 7000)of Division J ufthe Buxom ad Precision,Code.mJ my license
in full force send ec (J/'' `
oLicence^^^BBtk,,sn Curr t
3 Ualc—' S DF,ac ARA N 1 .O
G O roa. my plans", I bloc oNn
ga�y�
W i O Licensed Precol al
OWNER-BUILDER DECLA ION
e "4— I mmW affirm chat 1 am exempt fmm the onmactoi s License Law for the
Z a following mown.(Section 7031.5,Butitmss and Pmfecsions Cade:Any city of county $4000
E F o which rrquircs a Permit to mnstmct,alter.Improve,demolish,or repair any structure
I'3 ctm .,Into as icwvxe.vlso¢quims me applicant forsucn Permit o file asignodstmmemt
— mvlhers licensed p...tinnuothe provisions ofthe ConlrxtiliLicense Law(Charger9 5;q- Fts"O ea Valuation
(commencing with See tion 7000)of Division 7 of in Bali Pass ad Pmfesxiam Cade)
3506' �2`I .VU
m that he is exempt demfmm and the basis fonts alleged exemption.Any volition
of Section 7071.5 th ey...liemn Car a perms subjects the applicant to a civil penalty Occupancy Type
ofrunroethanfive hundreddollars Wig). 202 'PNJMIFLOOR PL BING
01,as owner of the property.or my employees with wages m their sole compenvtien. —
will do the work,and the suuawc is not intended or nffemd for.sale(Sec.7044, 502 — FINAL PLi [�11t1 n; H4'261
Business and Pmfendons Cole:The Conan,'.License Law does nm apply to an
owner of property Who Wilds or improves tenon,and who does such work himself 507 - FINAL PLUMBING
or though his own employees.provided that such impmvements are not Intended or
.Beced for vie.It,however.the Wilding or impmven¢nt is suld within one year of
completion,me owner-builder will have the burden of proving that he did nut build or
improve for purpose of sale.).
01,as owner of the Prnpi am exclusively camracting with licensed contocton in
construct the project(See'RW,Business and Professions Cude:)The Canuxmr's rr� rs'n 11 /nl �t�
License law doe no apply to an owner of property woo Wilds ser improves dtcmom, F B V A lG
and who contracts for such Pmjecu with R sontrategM licensed pursuant to the
Contractor's License Law. ,B ffi P C for this.mon 2002
01 am exempt under Se . AUG 1 3
Owner Date
WORKER'S COMPENSATION DECLARATION p y
I hereby a irm under Fervidly of Perjury one of the following deCarru nm: BUILDING
0 1 have and will maintain a Certificate of Consent to self-insnrc for Worker's
Compeesatiun. m pmvideJ for by Section 77W of the Labor Code, for the
performance of the work far which this permit is issued.
01 have and will mainerin Worker's Compcnvtion Insurance,us required by Section
37W of the Latin Code,fur the perfurmance of the work far which this permit is
issued.MyWPWers/oran
�rk� Compensation Insurance cartierr aand Poli umbo
Carrier.6`I"If=(hUY l Pam
olicy_No •�' , n^ �r��
CERTIFICATION OF EXEM N FROM WORKERS'
COMPENSAT10 SURANCE
('rain section need not be completed if the permit is for one hundred dollars
(k I W)of lea)
I certify that in the periannince of the work For which this permit is issued,I
,Wil not employ any person in any manner on as to been.subject to the Wmkeri
Compensation laws of Caffomia.Date
Applicant
NOTICETO APPLICANT..If,at mnkin,this Cenilictn of EwinfAion,you should
Z become subject to the Workees Comp nvuan Provisions nfine Lbar Col you must
z Q fon W,in comply with such pmvinions or
this permit shall be deemed revoked,
T3 CONSTRUCTION LENDING AGENCY
a71 h9rcby vdimm that mere is n construction lending agency for the performance
W of the work fm which this Permit is issued(sec.30x)7.Ci,C.)
Q Lende(n Nome
z Lender's Address
V 1 certify that 1 hove rcud this apPlicmion send swtc thio the(clave information is
lar F rormed.I agrte so emnply with sell city and ectomy arJinnnces send none laws,dating
Q T, to Wilding conwmction.and hereby authorise retrtsemmiws of lois city me micro,.
the above-mcminneJ pmpcnY fo(inspcsion Purposes.
W (Wc)agrcc msave,indcmnil'y and keep lmrnilcss the Chy of Cupertino ngainst
Vi liabilities,judgrnenn,casts and expenses which may in any way vmrue agaimt aid Q n�
U City in canscyucnce of the gmming of th .crmia II S(/(/
APPLICANT UNDERSTANDSAND LCOMPLY WYTH�.L ION-POINT Issued by: Date
OU CE REGULAT 0 1�� J
signawrta man✓r,n rata uTl7 w Re-roofs
RDOUS MAT LS DISCLOSURE
Will the upplicnm nr fuwrc building cupum same ser bundle hmvNwnmtcrid Type of Roof
nJ Safety
de.Sa by 1be Cupertino Municipal Cade,CM1upmr 9.13,and the Health.
Cale,Se
Cction 23532017
oven o All roofs shall be inspected prior to any roofing materia] being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
unit hvanlous air nndnnain ous as dei Pied by the Bay Area Air Quality Management
Drool all new materials for inspection. Applicant understands and will comply with
0 vat all non-point source regulations.
1 have mad the nazvdorus_ma¢riads requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25577 and 25574.1 undentrnd that
Hire building does irdennentle havcmm�un shin his any rcnpaosibil'uv to nmify the
mentons of the rtgaimments h Ela must el Prior m isw aiec of a Cenilicaw of
0-tipvncri S: Signature of Applicant Date
rat ti.edage t Dam All roof coverings to be Class `B" or better
OFFICE