02100013 (2) CITY OF CUPFRTINO z °'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:'
Basil- i4A019ESSUTHERLAND AV CUPERTINO PLUMBING PERMI'PN02100013
ow*IANGRUM JAMES E JR AND RUTH 3 10297 S DE ANZA BLV APPLICATTrUy1B»1Tr 2002
Ak
IFHONE: 4 0 8 2 5 3-0 618 SANI'T'ARY NO. CONTROL NO.
ARCIUTECf/ENGINEER: BUILDING PERMTr INFO
RLDG ELECT PLUMB MECB
cai00 LICENSEDCONIAACIT)R'S DECLARATION JilyhO O O O
as m p 1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing COPPER RE P I PE,Awt�R2ffIPST2V I CE
ti<i with Section 7lggBnf Divisinn Softhe Basionessand Profession Code,and Any license is
t-
in lull line and effect Ad ,021q . -p A `III LFUNALED
i�t f , nd 'b .h T
dodo
w3 LieenedP OCT 2 d 2002
HmOa O NER- ' IL RUEC RATIq1
<i l neren A torn,mal 1 am�xem uatr s Liemnse law BAr Am
$5500
01.2
o Edlowing rtuwm(.Seclinn TULs.Business anJ Pndceu'nns Code:Any miry nr county
e'K m 2 which relimms a Permit hi ft,mnucl,alter,improve,demolish,or repair any structure 1
aaN prior to its lSivamTa
. sarpcluac.t the applicant l ourch Permit lel file aslgned SlacarenI
1— That he is licensed puramatin the provisions of the Contractor's License law(ChepwrY ) Valuation
(commencing wit section 7000)Ad Division 3 of tk Business and Prosessinns Cook)or
Wtat he is exempt therefrom end to basis fertile alleged exemption.Any violation of
Section 7031.5 by any applicant to,A permit subjects Able Applicant Ina civil penahy of PN N Occupancy Type
nm roma than file hundred dollars($500). 301 - ROUGH PLUMB I G
❑Les ownerof to property.or mY emphryecs with wages az tksr role compensation.
5132 ji
will do the work,and de smucturt is not inendcd or offered for sale(Sec.7064,Business ®W r
and Professions Code:the Cnnmaue
or's Lnlaw arcs not apply to an owner of 507 — FINAL
INAL AL1 sections
property who Wildsor improves thereon,and whodrcs such work himself or trough his
,.A empinycea,pmNde i lhauuch improvemenB are not intended oroRertd for sale.IL
bmveven to Wilding or improvement is sold within one year mcompletion,to owner.
builder will haw the burden of proving Net he did not Wild or improve for purpose of
sale.).
1,as owner of the propeny,am exclusively contracting with licensed Ctm orcums to
consumer to project(Sec.7064,Business and Professions Code:)The Conbxtr's Li-
ccmc law does not apply to an owner of proper who Wilds or improves Lemon,and
who connacea for such Projects with a cunuaclor(s)licensed pursuant an dre Contramr's
License law.
❑1 am exempt under Sec. .B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby of Tin under penalty of perjury one of the following declarations
I have and will maintain a Certificate of Consent o salt hr ure for Worker's Compere
73700
ion,as provided for by Section 3710 of to"No Code.for the performance of the
work for which mss permit is issued.
I have and will maintain Wicker's Compensation Insurance,az required by Section
of to Labor Code,for the performance of the work for which this permit is issued.
y W)rkRaCZFpIlO Insumme carrier and Policy rn'umpMnrt:
mcf: sc�rccvNl� Policy Nu: /I 0)U/VIT� 0(r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE
(This semina ncN nal k completed if tc permit is foronc hundred dollao($101)
less.)
I certify that in the penmmance of the work for which this permit is issued 1 shall not
employ any pemm in any manners)us to kenmeaubjecl In the Workers Compensation
laws of Cahromia.Dare
Applicant
NOTICE TO APPLICANT:If.Asir making this Ce ilicate of Exemption,you should
WCuAAC subject m the Worker'a Compensation provisions of the LaWr Cotte,you most
OO R,rlbwsth comply with such provisions or this Permit shall W dmmcd rcvokcd.
z CONSTRUCTION LENDING AGENCY
Fro I herchy affirm that there is a construction lending agency for the performance of
C 7 tW.,it for which this peon it is issued(Sec.3097.Ci,C.)
Lx7 0UmAl'I No
a. Lcrom,'s Address
V O 1 unify that I have read this application and state that me above informatina is
U. (—' correct 1 agree to Comply with all city and county ordinances and state laws mining to
O V Wilding conumniun.and hereby autnrsa rcpo,wrom es or thisoly ,,enter urym the
alive mentioned property for ineplection pugmes.
F1 (We)aglce Io sa .indcmnssy and Ase�p hat I'm the City of Cupertino against 42 El
N
liabilities.j Bmcnu A van �apcnsc whichm many way accmc egainm aaiJ City rl i
UZ in comm. cE of c rami oflhis /v a'"O
AP LI 'f -RST NDS 'LL OMPLY WITH ALL NON-POINT Issued by:S4(AzW Date v
SOURC E A
Re-roofs
S' mum fAppli nV rr Date
IU ZARD US MA'Z'E IAL$ SCLOSURE Type of Roof
I to applicant or future mg rceupanl store or handle hrmudous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the health And Safety
Clae.Semtom2ss32(a)7 \ _ All roofs shall be inspected prior to any roofing material being installed.
0Ye, Ali
INn
Will the applicant or future building neAriam sae equipment Airdcvices which [f a roof is installed without thirst obtaining an inspection,I agree to remove
mil ha mdous air contaminants as defined by the Bay Arca Air Quality Managcmcm all new materials for inspection.
Disuse?
❑Yes IQ No
I have read to hamrdnusmAria s requireme tsytrdcr Chapter 6,95 of the Calisor.
Aria llmallh&SalctyCodc.y5{iunns 2533 and n 5311 undcahmd half the mining
does nor cunemttyy hart, ren u, lint i I res WHAM,to nobly tk occupant nl the
,fiireorms wN'I'h ono Ir I,no a, )faccndicAtemaama+eX' Signature of Applicant Date
U . U 2- All roof coverings to be Class"B" or better
masa t v<da Net Date
CITY OF CUPERTINO "' .' i. . '
BUILDING DIVISION PERMITCONTRACTQR INFORIAT,I, bN H,
eU1LDING ADDRESS: PERMIT NO.
CUPERTINO PLUMBING 02100013
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY OL NO.
is
ARCHITEC IEPIGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0
'LICENSED CONIRACI'OR'SDECLARATION Job Description - — --
U.F 1 hereby affirm that 1 am licensed under provisions of Cha% m
er 9(Commencing
with Section
rceandlu)of Division Sof the Business and Professinnx Codc.and my license is
� in full force
% x /
�qLicenclasn Lk,e. COPPER REPIPE/WATER SERVICE
Z= Dam Centocor.
ARCHnE DECLARATION
u I(
I undcmmnd my plans shall be used public records Qj -a 2,—
D e. �Q
C. Licensed professional 1 _:
3 OWNER-BUILDER DECLARATION
!� I hereby oRrm loan I am exempt from the Conusctofs License Law for[be
EeE sso
OD following.I n.(SCNun ID3strct,.boss and vet tiuu Cale:Any city arcounty
K m which its issio r permit rit)e cn.swn,ppcq.i t I.,so demolish, fie.sig eny structure
°zy pnprmitsiuuemc.also mquiruthe applhcantforsuchpermitmfileasignedsummmt Value O
< thmbeislicensed pursmnuothe provisions ofthe ComencmrlU..Law(Chapter 9 Sq. Ft. Floor Area
(commencing with Section 7")of Division 3 of the Business and Profession.Codc)or
'y dot he is exempt therefrom and the Buis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a penal,subjects the applicant to a civil penalty of 3 gVE-Migtpero 0 Occupancy Type
not mom Nan five hundred do1Ws(5500).
ci 1,as owner of the peony.w my employees with wages as their sok compenation,
will do Oe.,it.and the.wcture is not Committed woRered forale(Scc.]D6a,Business Required Inspections
and Profeammo Code:The Canuamor.License law docs not appy m an owner of q P
progeny who builds or improves thereon,and who does such work himself or through his
own employees,provided tat ch improvements are not intended oroffered for Ne If. __ -
however,the building.r improvement is sold within one year of mmpledon On owner
builder will haw the burden of proving Nu he did not build or improve fur purpose of
ak.I.
❑1.as owner of the property,am exclusively corseting with licensed com elan,in
cm rdocr the projem(Sec.1044,Business and pospe isiou Cotte:)The C.macmr',Li
cents w ladoes not apply ro an owner of property who builds of improves thereon.and
who convects for such pmjccu with a conuacmr(s)licensed pursuant to the ContramoYs _.• -� _ ._
License law.
❑I am exempt under S.C. ,B&PC for this soma
OwnerDam
WORKER'S COMPENSATION DECLARATION
I hereby afford uni pevlty of perjury one of the following declarations:
1 haw and will maintain a CcAfcam of Consent he selGinsum far Worker's Compere
Ic"
tion,as provided fw by Section 3100 of the Lobo,Code,for the Pcrfwmance of Ne - ---- -- - '
W
for which this permit is issued.
1 haw an,will maintain Workers Compensation hhsunnes.u required by Section '
00 of hoc labor Code,for Ne performance of the wwit for which Nis permit is issued.
y Worker',Compensator Inurance carrier and Policy number am:
rtier: Policy No.:
CERTIFICATE OP PREMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbecompleted if rhe permit is foron,hundred dollars($100)
or Ices.)
1 ccrvfy thin in the performance of the.,it for which this permit is issued,l limit not
employ any person in my manner so a m become subject be she Worked Compeosaton
laws of Celifomis.Date
Applicant
NOTICE TO APPLICANT:If,arm,making this Ccniricare of E¢mphion,you should
become subject to the Worker,C..'ree um proviatma of the Lahr Code.you muse
.J O fordwith comply with such provision or this permit shall be deemed revoked.
z CCONSTRUCf10N LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
a 7 the.,it for which Nis permit is issued(Sec.3091.Civ.C.)
u7 Q Lender'.Nam,
G Lender's Address
U O 1 certify that 1 have read this application and state that Oc show infomutun i.
Pcomm l agree to comply with all city and county oNinsnces and sum law.relating to
U building construction.and hembyaurhodm¢pm-unmivesof this city m emerupnn Be
�•'tl3 above-mcmmed pmperry for inspection p rposss.
(~0. (We)agree to arc.indemnify and keep blood.the City of Cupertino against
N liabilities,judgments.costs and expenses which may in my way accwe against aid City
U in consequence of ort granting of this permit. Date
�-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Appli,mOCom.Im Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applied.,or rurum Wilding uccup.....om w handle hrrallou material
as defined by the Cupenom Municipal Code,Chapter 9.13.and the Health and Safety
Code.Section 35533(.)1 - All roofs shall be inspected prior to any roofing material being installed.
❑Yes C]No
If a roof is installed without firs[obtaining an inspection,I agree to remove
Will dm applicants or future Wilding occupant um cquipmen,or devices which
it h....do.,air contaminants u dcfired broom Bay Aura Air Quality Management all new materials for inspection.
vial
❑Yo 0 N
I have mad the W.mI. .mamriair requimm,nu unJer Chapter 6.95 of the Calif.,
ria Health&Safety Code,Scetisms 25505.25533 and 25534.1 undcrsmnd that if the building
does not cur,mly have a unant.Out it is my responsibility m notify me occupmr of the
mquirem ntswhichmulabemelpriorto�uahnceofaeerdficamorOccupancy. Signature of Applicant Date
Dam - All roof coverings to be Class "B" or better
Owner or aathud><d sent