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04010100 (2) CITY OF CUPERTINO ' BUILDING DIVISION PERMIT ,CONTRACTC7RINFQRMA_KJON: • BUILDING ADDRESS: CUPERTINO PLUMBING PERMITNO04010100 OWNER'S NAME: PERMIT LSUE DATE EDISON FON ONE; SANITARY NO. CONTROL NO. (408) 253-0618 ARCHG EC(ENGINEER: UILDING PERMIT INFO BLDG �Ba�L' PLUMB MECH 38p LICENSED CONTRACTOR'S DECLARATION ZC I hereby affirm that I am licensed under provisions of Chapter 9(commencing - Job Description ✓'4 <U with Section 7")of Diviaion3 of the Business and Professions Code,and my license is �„ in full force andcffen. � Leg L�2G COPPER REPIPE �2Qy qz Licensed a .. 2 gF,o Data T*!iD CL I& 1301 9Q� ARCHITECTS OECLARA ON - !s( a� I undersnnJ my plans shall be used as public rccnrJs JyU ;in Licensed Pmfc3sinnal S OWNER-BUILDER DECLARATION ComraON E a E 1 resio affirm on 1 1. exempt from the Cssions o License Law for the ' m which uiresa(Section 7onstr Busino, and Professions Code:Any city or county which its requires issuance,permit re cores the,altopplic improve,dcmrilb�hh penmen fi repair any taructure tement that heor itsensed pursuant the applicant forthe sucContractor's ice a,Lawned mhaptert nnn yo (comm islicensedwith Section 7 the)of Divines of the the Bincros.rd enselsw(C Code)or Sq.Ft. Floor Area Valuation H (cat he (commencing SmaVons and m basis far of the Businessand Professions Cn�Qof $ Net he a exempt therefrom entl Ne buffs for the alleged cxempuon.Any violation of Section 70313 by any applicant for a permit subjects Ne applicant to a civil Penalty of 3%73304illeS O 0 Occupancy Type not more than Eve hundred dollars($500). ❑1,u owner of the pmperty,or my employees with wages u their sola compensation, will do the weirs and the sW=IYm is not imendCd or offered for sale(Sec.70 ,Business Required Ins actions and Professions Code:The Contracmr's License Law does not apply to m owner ofp pmpeny who builds or improves thereon.and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale,IL however,the building or improvement is sold within one year of completion.the owner. builder will haw the buNen of proving Net he did not build or improve for purpose of .In.). ❑h as owner of the property,am exclusively comncting with licensed contractors to _ consumer the pmject(Sec.70,14,Business and Professions Cade:)The Contractor's U. acme law does not apply aro an owner of property who builds or improves themon,and who contracts for such projects with a consio or(s)liunsed pursuant to Ne Contractor" License Law. 1 em arempu under Sec. .B&P C far this reason 1371M ner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declentions: 1 have and will maintain a Certificate of Consent to self-insum for Workers Compere u provided for by Section 3700 of Ne Letter Code.for the performance of the k for which this Permit is issued. I have and will maintain Workers Compensation Insurance,u required by Section of the labor Code,for the performance of the work for which Nis panni,is issued. Workers pmPmtsmimi once ctvier and Policy number amrier. S -e V7 o` Policy No.:6 00-7L b W CERTIFICA OF EXEMPTION FROM WORKERS' _ COMPENSATION INSURANCE (This section need not becompleted if the Permit is for one hundred dollars(5101) or less) I certify Nat in the performance of the work for which this permit is issued,1 shall not employ any person in any mannerso u to become subject o the Workers'Compensa0on.. Laws cf California.Date Applicant NOTICE TO APPLICANT:IL after making this Cenificoe of Exemption,you should become mhjeet to the Worker's Compensation previsions of the Labor Code.you must .J z forthwith comply with such Previsions or this permit shall he ticcmed mvokcd. z rte~. CONSTRUCTION LENDING AGENCY [—r I hereby affirm that there is a construction lending agency for the performance of Cli > Ne work for which this permit is issued(Sm.3097,Civ.C.) W Leader's Name � Q is z Lender's Address U Q I choir,Nn I have read this application and sum Our the above information is u, (~ correct I agree to comply with all city and county ordinances and state laws relating I.C V building construction,and hereby amhorim representative of this city to enter open the elwve-mentioned property for inspection purposes. W (WcI agree7q save,in�ammfy and ke harmless the City of Cupenino egeinn 4-?h liabilit7u,judgm�.mas)ndepcnsesw-hmaymmywayacervcagainstaaid Cdy V 7 in conseq rte 6666f the 8r 6tin6 of his Per u. r7 APPLI U E STAN AND ILL COMPLY WITH ALL NON-POINT Issued by: Date EGDR. G Re-roofs rc of ApplicaHAZARDOhric"rS ,ERI SDISCLOSURE„ Dem Type of Roof Will Nc applicmtm future building dupanl store or handle horardous material u fined by the Cupeninq Municoipal Code,Chapter 9.12,and the Health and Safety edr.Section zss3z(a)? ❑Yeas \/�_„p All roofs shall be inspectedprior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is.installed without first obtaining an inspection,I agree to remove it havardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. istricG ❑Yes, •�u ' I '' r' ,see, mater41a ndar Chapthr 6.95 of the Calding nix He & cry �,SccJ 2x5d NatiThuilJingt ty, avem M, ity b nodl'yNcoccupantofilia •sear purrmatmor =uPmcy. Signature of Applicant Date �. w cr ser amhmimd agent Datm - - All roof coverings to be Class"B" or better CITY OF CUPERTINO d ' REPIPE/SEWERS/MAIN SERVICE IT F CUPERTINO PERMIT APPLICATION FORM\ APN# �`7 1 • b. Date: Building Address: Owner's Name: LI , s -H C15 Contractor: Pone: License#: lno ban * �� ��, 2L4,qoS Contact: Phone- Cupertino Business License#: Card I a �v�� Bud ding ermit Info: / Bld Elect E3 Plumb L9' escription: Residential" Commercial ❑ Cost of Project: OGD • Qty. if Applie Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permdt Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWS VCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING