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03100038 (2) . CITY OF CUPERTINOk^' rw BUILDING DIVISION PERMIT 'Co NTRACT,OR INFORMATION ",: au1LDING ADDRESS: SHEPHERD SERVICES PLUMBIN ER9TND03100038 OW NER'S NAME: 10121 IMPERIAL AVE PERMITISSUEDATE NE` 4085597160 SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: 'BUILDING PERMIT INFO BLDG ELECT PLUMB MUCH !O0 LICENSED CONTRACTOR'S DECLARATION' ] b Description I u G I hereby affirm that (3SCTI Thal I am licensed under previsions of Chapter 9(commencing p / U wilh Scnion7IXX1 of Division3of die Business en Prufessiuns Code.md my lice..is 'p s I, cls C,31i g >� in c I NEW GAS LINE Date cralmnt INSTALL APPLIANCE-CONVERT EXISTING Q J qq ARCHITECTS DEC LAR oN IZ-J;Cf.o ELECTRICAL V ig IundcraonJ my plain shalibcusdu pufd records teu 'a(n Licensed Proressi...I r OWNER-BUILDER DECLARATION 1 a I 1 hereby affirm that I am exempt from the Contractor's License Law for the =0 0 following reason.(Section 7031.5,Basin.and Panfessime,Code:Any city in,many Z m which requires a permit m comic act,alter,impmm,demolish,or repair any structure iprior to its ismonce.also rcquira the applicant for such rermitto file a signed statement F� that he is licensed moment to the provisiomr(the Cmtraeuxo License Law(Chapter 9 Sq.Ft. Floor Area Valuation F (commencing with Section 7")of Division J of the Business and Professions Code)or that he is exempt theim(mm and din how for the staged exemption.Any violation of $1000 Section 71131.5 by any applicant for a permit subjects the applicant to a civil penalty.( - APN Number Occupancy Type nut more than Rve hundred doll...($500). ❑I,as,owner of the pmpeny,or my employees with wages as their nle compensation, 35710002 . 00 will do the work,and the swcwm is not intended or offend for sale(See.7014,Business and Professions Code:The Convector's License few does not apply to an owner of Required Inspections property who builds or improves f orcon,and who d.essuch work himselforthmugh his own employers,prodded that such impmsemeno s.not Intended or offered for sal..If. 106 — SEWER & WATER however,the building or improvement is sold within oro year of completion,the owner. I builder will have do burden of proving thel he did not Wild or impmsc for purpose of 202 - UNDERFLOOR PLUMBING El 1. 301 - ROUGH PLUMBING I,ru owner of ct Se.,70..B exclusively convening with:)71becd contractorsContractor's to connrvct the project(Sec.7004,Business and Professions Ch0e0 The Comnnor's Li. 3O2 — TUB & OR SHOWER _ cense Law does not apply to an owner of property who wins or improves themon.and, 502 — FINAL PLUMBING ENERGY who contracts for such projects with a eomnclons)licensed pursuant the Contractor'. se, Law. 506 - GAS TEST ❑I sexempt under Sec. .B&P C far this resson 507 - FINAL PLUMBING Owner Dale WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury ore of the following declarations: I have and will mainuia a Ccniftcme of Consent o self-insure for Worker's Compcm mlion,u provided for by Section 37W or the lever Coda(or the performar.e of the work!or which this permit is issued. Cl 1 have and will maintain Worker's Compensation Insurance,ss required by section J?IXI of the Tabor Calc,for the performance of the work for which this permit is Issued. a Worker' Campenemaw Insurance cmar,and Policy n� �re: 2 Carrier. e I— Po o.: 5 l� CERTIFICATE OF XEMOM WORKERS' COMPENSATION INSURANCE (This section recd not wchmpleted If the Perm,Is Iran.hundred callas(SIM) or lac) 1 certify thin in the performence of the work for which this Permit is ismed.I shall not employ any person in any manner so as or hecmme subject n the Workers'Compensation Laws of California.Date APPlfcant NOTICE TO APPLICANT:IL offer making this Cenifcare of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or His perm it shall he deemed revoker. .N. CONSTRUCTION LENDING AGENCY 1 hereby affirm that them its eomtructinn lending agency for the perfurmance of 34 > the work(ser which this permit is issued(Sec.3037,Civ.C.) ' 4 in Lendces Name =z Leaders Address j 0 1 century Nat 1 have read this applicuion end tote that the above information is , F coacm,l agree 10 comply with all city and county on inances and mule laws relating to DU aboye.gcntionedlfamend hereby archon ureprtsenulivcs of this City 0enter upon the �G ehnva(We)agree to ertysave for inspection an Purpo.a. y (We)agree to cove,indemnify and kith harmless the City of against Said id Ctagainst fA liabilities,judgments,Shooing cxpen.srnIt, may in any wayaccme againstsold City j in eonuyuenec of the granting of this permit. APPLI ANT DE AN 5 AND WILL COMPLY Wto I&IT ALL NON-POINT Issued by: Date OUR REG LATI S. 6 Re-roofs Oreo pplicam/Canvaclor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Wit the applicant orto,=wilding Occupant store or handle haluduus material as deMcd by the Carnahan Municipal Code.Chapter 9.13,and the Health and Safety nen,Scotian3ss33t.)? �_ ea All roofs shall be inspected prior to any roofing material being installed. Y Will the applicant oa future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove It hazardous air contaminants a defined by the Bay Arca Air Qual fly Management all new materials for inspection. 7d- ❑YesI have real Ne hanNrus materials requirements under Chapter 6.95 of the CalifonHealth&Safety Code,Sections 25N15,25533 and 25534.1 undersoM dW irom wilding s notetammlyha a. n 1 it u my respousihilitymredly occupantofthe ul me wh tithe t 'dill ccrfaCpi[i u ancy. Signature of Applicant Date een author Jegcm /lJ (f/ Dan, All roof coverings to be Class "B" or better CITY OF CUPERTINO 4 0 3 W O REPIPE/SEWERS/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN # OI Date: Building Address: �\ �� Owner's Name: I Phone#: C ntractor: Phone: License#: s �Pd 3 Contact. Phone: Cupertino Business License#: Cv Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Job Description: r Kvo 4(1,0 �10J— \YL I _ r4- E?x,4\ 4c1 Reside al Commer is ❑ Cost of Project: Qty. if A li e Fee ID Fee Description Fee Group PPERMTTFEE Plumbin.g Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING 23377. z0- c;,Q — S