02100195 (4) CITY OF CUPERTINO 'aha "�^ '�' '.
BUILDING DIVISION PERMIT �GONTRACTOR INFQRMATIQN: s..
BUIgDD2Agp4INICKSBURG CT NEW STRUCTURE PLUMBING IN PCRMITNO2100195
Owd1ASNAME: P .0 BOX 111145 APPLICAT(POSP15"1TY2002
orONE: 408 364-2145 SANITARY NO./ r CONTROL NO.
.I ARCHITECT/ENGINEER: BUILDING PERMIT INTO
I+ _ BLDG ELECT PLUMB MECn
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION
W iF I herchy affirm that I am licensed under provisions or Chapter 9lcommerein Job Description
M<� with Section 7XXB of Di 'sio 3nf the Business and Profewinns Code.nn0myliccnses COPPER REPIPE P
in loam meet. -
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C'-36Lie.»��'' 7 Y IN
OZ—p D.c Contras -�—�—>
l understand my phossull be used a.Pthfie cord ^
APR 9
W LL 2 LiecnmJ Pndessinnnl
C—p Oat I am exempt
from
DECLARATION 0
0
I herchy.(firm that 11. exempt s an she Contractor's e:Any c Law for the w yS 6 2 0
m—p 0o following reason.(Section]1131.5.Business and Professions Code:Any coy nr county u+ 111
6 X 2 LL which requires a Permit it)consWtl,alter,improve,demolish,m repair any sometuR X./
Hai
Poor o its issuance,also requires the applicant for such permit to File a signed statement
<
dow he is licensed pursuant to the provisions of the Comm,om.s Lice nsc Law(Chapter 9 3S49QY410l WILiation
QFC (commencing wi in Section](XXI)of Division 3 of the B usiness and Professions Code)or
y $ That he is exempt henchman and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of /UAPNN99RW�UHOccupancy e
him mare thfits hundred dollars(SSW). 301 - ROUGH PLUMBI G p YTYP
❑I,as owner of the recruit,or my employees with wages is their sale compensation.
will do the work,mad the sBoqure is not intended or offered for We(Sec.7044,Business Ili, ENERSY
p��r
and Professions Code:The Convectors License Law does not apply to an owner of 507 - F I NAL Cf Ivy &ectlons
property who builds or improves thereon,and who does such work hinewifor through his
own employees,provided that such improvements are not intended or offered for We.If.
however.the building or improvement is sold within one year of completion.the owner.
builder,will have the burden of prating drat he did not build nr improve for puryose of r
marc.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct dm project(Sec.]1144,Business amt Profosiolls CW,:)The Contractors U.
cense law does not apply to an owner of properly who Wilds or improves themon,and
who consents for such projects with a cors anm(s)licensed pursuant to she Contractors
License Law.
I am exempt thder&c. ,B A,P C for this reason
Owner Data ,
WORKER'S COMPENSATION DECLARATION
1 hereby anion under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Comentto self-inmm for Worker's Cnmpen-
smion,as provided for by Section 3710 of the Laher Code,for the Performance of the
work for which Nis pemlit is Word.
❑ I have and will maintain Worker's Compensation Insurance,as required by Sectio
37N)order labor ,Cede,for the performmce of the work for which this permit is issued.
My Worker' ompenuti,n ln�surznce caaierand Policy colors. pp
Cartier: &Iize! /ij Polis �Y Rs
xj CERTIFICATE OF EXEMPrIGN OM WORKERS'
COMPENSATION INSURANCE
(This section returned be mmplevd if the permit is forone hundred diAlars(SIM)
or Ices.)
1 unify that in the Performance of the work for which this permit is issued.l Mall not
employ any person in any manners,as m become subject o the Workers'Compensation
Laws of California.Delo
Applicant
NOTICE TO APPLICANT:IL after making this Cenific de of Exemption,you should
become subject to the Worker's Compensation Provisions of the Labor Code,you most
OO forthwith comply with such provisionsor Nis permit shall be deemed revnked.
z "t CONS'TRUCr10N LENDING AGENCY
E7) I hemhyaRrm drat there is a conSWetion lending agency lir the performance of
Citi the work for which this Permit is issued(Sec.3(197.Civ.C.)
LW D Lender's Name
I� 1<Wcr's Address
oz
C.)0 1 comfy that 1 have read this application and state that the shote information the /t
W fa correct.l agree to comply with all city and county ordinances and state laws relating to
Q V building construction,iedroand herby awhon purposes.rsexnd.ives or Nis city reenter upon the
Gj abnvn(We)agree
u. rcerty for eminil innkeephand
a
1 (We)game m save,iodcmni ly and keep harmless the City of Cupensto against
V) liabilities.judgments,costs en nus which. in any way accroc against mid City /
C.) z mconscyucncc,f the gra gof Nis permit /
'—' APPLICANT UND TANDS AND COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG I NS
�m 3c_ Re-roofs
arc of ApplicanclC,mraaur me
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle ha ardous material
as defined by the Cupertino Municipal Coot,Chapter 9.13,and the Health and Safely
crde.sIi,nszss3xa)7 `
❑Ye - All roofs shall be inspected prior to any roofing material being installed.
PI No
Will the applicant nr future buildingmmupunl use equipment,(devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit harandous air contaminants as,defined by the Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes
I have read the hexer nusmaterials requirements under Chapter 6,95 of the Cali Far.
niullcalNdt Sufn c,Scnin.2 ,25533.025534.1 undermand thtifthc building
does nod cuncnl etre a¢ or my responxihility In nndfy IW ..p.l of thc
rcquimmen i �isrtoiuu.ceof.Cerb c 3yQrfypancy.O� Signature of Applicant Date
rauthonxcd agent Date All roof coverings to be Class "B" or better