02050076 (2) pC1TY 0f.CUPERTINO -
BUILDING DIVISIONpERMIT CONTRACTOR INFORMATION:''
�BUI DINOADDNE PERMIT NO.. 02OSOO76
141'6'3.;;S1� TFFORD 'DR' GREEN FIELD PLUMBING.
"As itv
'CJ." K,.AND.`THECLA- M 3513 MADRID DR IA9 `7TMVTS-21z
! HONE:i , .. .. .. ... .-. .- .. _.....s
(408) 946-5150 .... ..• SANITARY,NO;' CONTROL NO.
ZXZ ARCHITEC M,NGINEF.R: - - BUILDING PERMIT INFO
awit ''s . i '• ' - _ BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION b
iZ ICC ,. . .:l hereby Bion that l am licensed insist provisions of Chapter 9(mme
mnnng RE-PIPE-3 BATHR�OI�Io
YcnV ATER HEATER UPGRAD
.whIb S«tion 7lgl(r)of Divi nn3 oft Busirxjax and Pummions Cale,and my license
ll e d Bc
O�U ' L meC Lic�1a�stq'
a S O t; s ! 1; R IT S DEClARATION
S �' ,r,^I it nJerslaid n y,pl W, W I I ha 4sed W p abl c:records- ,,.__-! ,
i ip O ,Lammed Professional
c f•• ', ' t OWNER-BUILDER DECLARATION - -
6 w s: 1 hereby.affirm that I am exempt from the Contractor's License Law for the _,.....__.................-$3000--
w -
t_a 'fono' rngreaxrn.Iseam;r744316,BaxirexxandP�nrexinn.enae:Anrci�y,�rcnuntr
F F C ;.'sLhich requires a permit to conxwc, a.hm,improve,demolish•or tepid,troy mare.
3 pntrt 1 reclaims the applicantf hpermul file ig dstatement - - - -- - ---- --- -
�cg rvr -
tlialh I sedp Itoth m sons fmcC vnctorsL Ise (Cwpter9 30a,7.n-G7,,h*E'.�I@a ., Valuation
(Erin acing with Section 7000)of Divisionl of the Butinesx dPore ons Code) r ti9 :_/tl +.\' li) _
or That he is c,thr t mctefrrm dad he basic for tln abelled demplmn.Any violation L ofSection 7031.5 by any applicant for a Permitsubjects the applicant to a civil penalty
1064RN I�IErrtfR- & WATER 'Occupancy Type
tr .axower ,seep, t'y, raretnpwy«xwimvvg,,:;xnieir;nmaimPnxnrnn, 202 - UNDERFLOOR":PLBINGr
will do'the'wak:and the stnnurc is not intended or offered for sale(see.71344, 3 01 - ROUGH P Tp�(� - e
Busincss'amd Professions Codc:The Contractors License Law does not apply to an w4Nr4fDS ectlons'
awml ofp perty Who Wilds or improvesmerernandwhoa n workhimself 302 - TUB Sc OR SHOWER.'
ba through hismpl ye provided that such impar,comma of intended or •. . . ENERGY,
• -
'
offered for l Inn ec,.tirenrlding-oitdpro:ementt, la 'm '_e yearn, '-- 502 FINAL PLUMBING,- ENERGY
completion.m proving that head not Wild or .. ..
owner-ladder have the buracn of 506 - GAS TEST
.t ,improve for Pt pose ser Salo.). cantmn ..
'd.I:az nw�er;t me property.ani excia.nuely m yin,with licensed edremetots 1n 507 - INA U I
F- L PL MB NG
;construct the.px,ject(Sm.700.1,Business and I'difessions Code)The Contractor's
License Law does not apply to on owner of property who builds or improves thereon, - -'
d- nr contract ror such'pr jecu,witl t t (s)licensed Pmarmat.1.the :. ,.. . .. ._�® - -. ... ....... _. _. ..._.... _. .... , ....
C nt tis 1 Law.
iNot!xcrrmv ad.,S _. _,B hPC forhisreAaon
n OM PENSATT>DFCLARAIK)N` ,1`,1YN f5 2002 _
,{1L I nerehy aft tltl de penalty oPperl ry of the following declarations:
/ s!d`la have ard: Ilftnammnsn lcen fcate of C 'cot If - for
Worker's ��/+ 'rt• t�_ s _
t ,C mpenmHon s pro dim I by S cton 371X1 f theLabor Cade, for the n,11LD Vr
peRonnance of the wurA ror wh ch this permits issued.
SOY huvu and will maintain Worker's Compenmtion k,tomce,vi required by Section - --- . ......--..... .. - . .. . ..
-3700 of the Labor Code:for the performance of meworkfor which this permit is
j,boamEMy Worker's Compensation lardomcecarner and Policy num&rate:
,Coir _P r"^'L 6 't't.Pobcy No._ t -. ., r •"' ^''fir', , '-\r's- I I,'
CERTIFICATION OF EXEMPTION FROM WORKERS, '
* " COMPENSATION INSURANCE'
,toe.' .}c .... ..... .._. .... _.._._-_ .....� .. .._._ - -_ k.z ......
I—t o7dr lsecuon recd our h ed ru
completne pe.it is for one hundred dollars ,
(g100l 4e,ls'.).. .. -
,- Icrf thainth
nvr Y a pert ce orde rk'f mm th pe .r is rssued.I \ ,
shall 1 Inplry any re i y t I mac h 1 to'he Worker,
Comp- 1 n.LrwR 1 f tNd D '. ,TT!o�^z ;
OAP 1.after making this C ti team at txemption.you should .. .... .. ..... .
bmo M1)c r the Worker's Compensation P vis Dns of theLabor Cad you must -
Q Q comply with such provisions or this pertnitthat]be deemed mwked.
H y '.• s�'C0NSTRUCTION LENDING AGENCY
;1 hereby affirm that then is a contraction lending apaq for the po fomunce
,.., ohhe work for which this permit is issued(Sm.2097,Civ,C.)
L'etMdg Name- .. . . .-.., - .. t- ....._. .. -..- ...__ . ._ . .... ...... _... .... .... ...... ...- " _.
Cr Lena Ada .
L.7'Q 1cedify[hot I have mad the rrpplicvuur and x ret efluo'hi, Wva inf.ornatim I,
W Es ar`ecr I agree to comply. th all city and county ordinances and state laws mining Y.
Q V
a.Wilding t et n nd hcmby mthorrimpoisentatives of1hs city to enter upon
} r�
the bo e nparamed property for irrocclionivirrule, ..
E,•,,,pt t'.,,._*y�Wd agree,t %i 4 ad1 fy cold keep h Its th C tyof C pert no ga ns1 - -
V] hob bues,3 dgm 1s,c u nd xp nsn which m), troy y e ago nt smd
UtZ tCiryncbscqucn¢of the gre_rngof this permit ry
APP ICANT UNDERSTANDS AND WIL OMPLY WITH ALL NON-POINT { I
$ iCEREGULATIONS - .. Issued by: Date
$ignamn of ApphCmI/Co DODSMATERIALS Date, Re-roofs
/ -- - --
1
„11 - DISCLOSURE' " -
! W ll(b'applicant or future building occupant store or Wrote hanrdous material Type of.Roof ... .. .....
Cod S t n 255321) t d Safety
is,,
s Cef d by N Cupcn Municipal Cade Ch pm 9.13 and theHealth an ,.
❑Y R t kf(tN , I' ,� - ' 'I' All'roofs shall be respected poor'to any roofing material being Installed..
Will she-ppima applicant i b �1a��'«eupart�xegap e t a tx�nien If a roof is installed without first obtaining an inspection, I agree to remove
.mit naiad c norm nuns as defined by the Bay Area Air Quality Management
Dist ct -' all new materials for inspection. Applicant understands and will core_ ply with
�NqI , all non-point source regulations; ..,
I have dad Ne haxurdous manrials regmrt ems turb Chapmr 695 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that .
iohewildingd«s;mIca ativ have a mann.that it is my mxprnsibility,to notify the - -
ocdupSm orme rcgaimmenii which m be met pd.,m ismanm of a Certificate or °-
oct p'"y . �'"' /c�0 Signature of Applicant - Date
t All roof coverings to be Class B or better'
O r nmhrri agent Date
Y ...
?� c: '',. . . .. _,-•.. � ." " OFFICE