00080076 (2) CITY OF CUPERTINO a PERMaNO.
BUILDING DIVISION PERMIT CONTRACTOR'>INFOR'MATION: O p g O O-7
BUILDINGADDRPSS:
L SANITARY N4 APPLICATION SUBMITTAL DAT
OWNER'S NAME: 20366 VIA PALAMOS BUDGET PLUMBING NIC - f Lx
PHONL, ❑
28695 ROANONE ST
,A R,I I I'DiCT/ENGINEER IULDING1'ERMrIM
MKz
��0 (510) 303-7847
U
F. 7 LICENSED CONTRACTOR'S DECLARATION
iv 1 hereby affirm that I em IncnsN maker provisions of Chapter 9(commends, Job Description
9 with section'f000)af Division 3 of the Bmimaa and Pmfmaions Cade.and my license is
yNinfullforteandeffecl.
i U Lianas class Lic.0
aLLH °° ARCHITComrwurrECTS WATERHEATER REPLACEMENT
O 6 ARCHITECT'S DECLARATION yl
�vW y� 1 undcrsrad mY Plena shell W used u publi<recards �_(y-I4/.//`_'g^(7
ii: Licensed c
Llccnsed Profcssiond
w Q-' OWNER.exerts,fr DECLARATION \V\
Fir I hereby sSocr Wal 113 exempt from Pe famon,tors License Law fou the
rH tete following ream.(gaiter-carat Boater.sed Rofmiom Code:Any city or County
whim rite is a pemhh re emuo0.alts,irritative.h permit m repair say amcnat Sq. Ft. Floor Area 11 u n
prim a iIIs iuumm,tete i to to the applicant foe amt permit Lima Uw(aulcm 9 v
Wal he is Ii«coed parsuant to Ne pmvuians of tied ConvamoYs License law(Chapta9
(commcnciag with Section 7")of Divid.3 of the Bminms and Hofeseions Code)Ca APN Number occupancyType
Wt he is exempt Naefmm and the basis fm the alleged exemption.Any violation a YP
Salon 7031.5 by any applicant for•gamed subjects to appluaat to a civil penslty of $700
pd more thm live hundred dollen(5500).
1,..mofthe propeny.cemyemploy«.with wages vtheirameeompammn... Required Inspections
will do the work,ad the motion isnot mounted to offered fm sds(S..7064.Basins
and professions Code:The Contractor's License law docs to apply to an owner of 31601. 1.90. 00
property who builds or impmvm thereon,and who d«,such work himself or through
his own employees,provided that such improvements art we intended ce offered for -
alaIf,house,the Wilding or improvement issold wihmmheyearaftamplaiW.We 106 — SEWER & WATER
ur
o nm4a ilder will have the buNcn of proving diet ha did am Wild m ino o ve for pun
poseofsda.). 202 — UNDERFLOOR PLUMBING
I.as owner of the IuopenY•stn exclusively Connecting with licensed Comments in
mnamtct the petrel(S..71N0.Business road Profession.Code:)The C..e.u- 301 — ROUGH PLUMBING
cense taw arcs cot apply an an owner of progeny who Wilds m improves thereon.and
who convects for such prej«ts with a Contractual s)licensed pursuant In the omniscient 302 — TUB & OR SHOWER
License law.1 am 502 — FINAL. PLUMBING ENERGY
exempt under Sec. B. &P C far this
Date. 506 — GAS TEST
Owns` WORKER'SCOMPENSATIONDECLARZiON 507 — FINAL PLUMBING
1 hereby sRrm under only of"J.,Dec of the following declarations:
O I have and will tnsinuin.Certificate of Consenuo self-insure fofworker'.Compem
cation, provided fpe Section 3100 of Lha labor Cade,fm ted penfomuree of the
work which this permit is issued.
37 1 have and will mdmdn he per of
week
Cor which
required by Section
my Whole's
the Iabm Cade,f«the pcdormarce of IW work f«which this Rrmit u issued.
My Carrier,
s Compcnsenioru Insurance curia and Policy number art:
Cartier. Policy FROM
CERTIFICATE OF COMPENSATION
FRAM WORKERS'
COMPENSATION INSURANCE
(This section coed not be completed i(We pemit is(Drone hundred dollen(SIM)
or Ins.)
I cenify that in the performance of the work for which this permit is issued,I Wall
not employ any person in any manner so as to become subject to the Worlke,v Compm-
union Law,of Cdifomin.Data
Applicant
NOTICE TO APPLICANT:if.after making this Cenifiam of Exemptloe.You should
femme subject to the Wankens Compensation provisions of the IaWr Code,you must
forthwith comply with such provisions no this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
Q Q Ihaebya imtha Wcmisawnst=Uonlcndingageuyfne perfomw«of
rZi the work for which this permit is issued(Sec.3097.Civ.C.)
ai Condos Name
_ Uder's Address
W I certify that 1 have read this nppli«tion and vote Net the above information is
A. zcovert.I agreto comply with all city ad county odimnces and sum Iowa relating to
.7. z e building conswction,and hereby mahonu m,mantslivm of this city to enter upon We
U O mov.-meMomd properly for imp«tion putpo,es.
kx F (We)agree to save.indemnify and keep humleas the City of Cupertino against
Q U Iiabiblus.Ndgmaatc emu and expenses which may in say way accrue against mid City
>. L4 in croseymoec of the granuag of Wit,permit.
[� 0- APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT
U SOURCE:REGULATIONS.
Signamrt of ApplicantlCmurectm Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamorfmum Wilding occupantsmre orhandlehasNous material Re-roofs
ns defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health send Safety T e of Roof
Code,Section V5532(a)7 yP
[-]Yo ON.
Will the applicant or future Wilding.,.Wt use mnipmcnr or devices which All roofs shall be inspected prior to any roofing material being,
'l handom air contaminants as defined by the say Area Ab Costly Management installed. If a roof is Installed without first obtaining an inspection
iavlcti I a ree to remove all new materials for inspection. Applicant
Oyer ONo
Ihawe rtae we hanrdwsmamrd,hecphinmmts amde"Chapter 6a5 of We Cali. un erstands and will comply with all non point source regulations.
faros Health&Safety Code,Sections 25505,25533 and 25536.1 undersond the if the
Wilding does runs cunnntm y have a tenant.dit is my responsibility to occupied
the
the rtyuverhmu which must be con prior w issuance do Cenivicem of Qcupancy.
Signature of Applicant Dale
Owner m euthonzed agent Ilam
All roof coverings to be Class"B"or better
OFFICE