00070137 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
FOILDINGAODRE.SS: - I'IiRSf I'I'NO,
(IWNIiR'S NA.1:: 165 SWAN eAlt i=A APPLICATH Q@AA "�
PHONE: SENqE ROSEMARY TRUSTEE & ET AL SANITARY Cfety , O.
p m zARCIIL'IBL71ENGINEF,R: BUILDING PER511'I'INFO
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z, LICENSF,DCONTRAC'IOR'S DE LAFATION ,lob Description
u' Iherchyliirm tbar lam Iicerivedunder pravi.inna of Chapter 9(commencing p
ONFOw with Sectim,71X1111 of Diveon lof lite liaeinecs lmA i'n,fussioro Cuda send my liccnre
Iv in full force and effect.w a Liccnm Class Lie.p
m
3 LL u Dale Comclor GAS LINE
fn AkCfil'1 F.CT'S DECLARATION
O
Tg I undenmed my pnms.hull be.,d a,puhh,mound,
cece
_
o O l,'acnwd Pn It"oural
e Lg Ibut I a exempt from
m the RAf1(IN
1 hereby anion than I Ion UILD from the ARAIIOol'F License Law for the
r z i whichNg uiresa. erttsection ani 15, t.alnees and rte. a moll end":repair
aura county
Yr�p witch l, re. ape ,in .t I Iter mttm demolish. p' Ystructure
i3m prat t sl.. , ,h ,plic.inithpemlitti)filca%ignedstalcment
he,he is licoovd,m,.ua, the lewilival rtes e I' I sl 1 e ode) Sq. FI. Floor Arca Valuatil
(cnhalhe ,wucl Ih,rI71XXq o(Division Bt e.1 ed Buse secsandior,Any
Code)
or that he Is sec rapt(any applicant
and the mein fur the subjects
applicant
Any t peounialinn
of Sectionedian by anyydred ollforapcnnil sunjmsthe applicant n,ucn'il Maalty
nn,s,I comedian eve hundred dollars lsSW). APN Number Occupancy pe
❑1,as owner of the property.or my en,pmycen with wages as their sole compensation.
will do the work,and the slectom is not intended or olferul for sale(See.7044, ` 3
Business and Professions Calc:The Convector%License Law d,x.s nm apply men quircd Inspections
ocaner of pmny Who builds or improves(hereon,and who does such work himself
r thlnagn hMi,own cmpinyecv_I led h.e.wen Impnrvcmem,are n I iolcnded m
offered for sale.IL however.the building or impmvemem is sold x;thin one year of 10E — SEWER & WATER
nmpldion,the owner builder will have the burden of proving that he did not build or
Improve mrpurpncol mle.). 202 — UNDERFLOOR PLUMBING
01,a,nwn".11 hepmpetty.ILon slbl:ivclycontracting with licensed Cantmcmr.it, 301 — ROUGH PLUMBING
comma the pmject(Sec.7014,Business and Professions Code:)The Commcmr'.( ,
Limenw[.aw does nolappl,oanounce ofpogacywnnbwBdsorimpmve,thereim, 302 — TUB & OR SHOWER
and who a ilea, liar such pejcctr with a cont mao«a) IiccncJ lmOrma to tnc
Cmaramer,LiccnKLaw. 502 — FINAL PLUMBING ENERGY
❑1a ' 1 al', BrvPcrurmi,reason 506 — GAS TEST
G ivolirc sCOMIHNbA'r1ONl)f.Ch;ARnfu)� 507 — FINAL PLUMBING
I heruby uvinn nnJer Mnally ser Pur,iury one of the following declafmlons:
❑ I have and will mainmin o Cenific to of Consent to self-insure for worker's
Comte ration. to pnwid,d fur by Section 37(X1 of the Lnbor Gds, for the
performance f.h,work for which this permit is..cued.
❑1 have and w111 n a main WnrAcr',Ganpen.naln t Inwrunca sea mluimd by Se,dun
JAX)of the Labor Calc,for the 1,•ofurol of the work far which this pem,il is
:-cool,My Worker's Cmnpen,cion Insurance carrier:rod Policy numhcr arc:
Currier: Policy No.:
CIiRN§CATION Op E%IMITION FROM WOIIKERS'
COAIPENSA ION INSURANCE
(This section need not he m... Itwd if the(email is for one hundned dollars
(SI W)or It,,.) _
I certify that in the performance of the work for which this permit is inued,i
shall oul employ tiny arwo In any manner so as to become subject to the Workers'
Compcnsmion Uru s of Culit...rim.Dare -
Applicant
NOT'ICH TO APPLICANT:If,after making Ibis Cenilicale of Exemption,you should
become subjecno the Worker's Con,pensmion provisions of the Labor Code,you most
Q Q fonhw ith Comply w 4th nucM1 MovisinncalLi,Mm,iuhall le,Jammed rc,oAeJ.
Fi CONS'rRucT ION LEINDING AGENCY
a 5I nereby anima ooet mere Is a...mu mlio i lending agency In the Mrfu romwe
rime work for which his permit is iswed(Sec.3017.Civ.C.)
0. Q L.ceder's Name
Z L,Cm1cr'e Adde-1
V I aniry that L htne mad Iho nppf,eliun and,late that the Chole monument,is
Le. 0 correct I agree it,comply with all city and county nrdineneu,and state laws elating '
Q f..) u,building construction.and hereby audience repeeensnlve%of this city h,enter upon
7 Gsthe a e,e-raentioneJ properly fan'is
peetion p rlpmc..
L.I W (We)agree to have.indemnify and keep harmless Nc City of Cupertino against
VQ liabilities,judgmm�a,mats attd C,wmes which may in tiny way onove against said
"C"nnce of Ne graadl,g til bis Mmol.
PPLIC NT UNDERSTANDS ANI ILL COMPLY WITH ALLN IyT Issued by: Di
m
E REGULATI NS. 7 , _/Q-�
"gone r�nrnppcmnntmonl taa palm Re-too
11ALAR000S MA'I 1?I21 ALS ...C'c"Ta? _
Will the applicant m mere buildin ,secapant stem or naalm hvudous,rurerial Type of Roo
to dclined by the Cupcnlnn MunicllnJ Calc.Cotp cr 9.12,mod the Health and sarety
Code,Section 255321.1'
❑Ye. 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future linking occupant aac equipment ordcvices which If a roof is installed without first obtaining an inspection, I agree to remove
Cnlu he,ardnus sir cnntaminanu as AcfincA ny Inc Buy Area Air Quality Manngcmm�t
DW,ia+ all new materials for inspection. Applicant understands and will comply with
0Yes ONa all non-point source regulations.
1 have mad the haradeas materia],regoimeemn under Chaptef 6.95 of he
C:Jih,mia Nesbit E S:dcty Cale,Section 255113,25333 and 25514.I understand IM1at
it the SullJing dlxs bol cu"--my ha mnant Wm'n is nay respa,siM1llilymnotify lbc
w he mquimmeme xti the and p��r m iwuunme of a Cer ifcme of
y n Signature of Applicant Date
bwncr-,amnd,ea.bent All roof coverings to be Class "13"or better