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01050118 (2) CITY OF CUPERTINO - BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: PERMIT NO OWNIIR'S NAME APPL1CNIION SUR DATE 05/141POOl PHONE: SANITARY NO. CONTROL.NO. OC ARCHITEClifENGINEER: BUILDING 1117RNIIIINFO BLDG ELECT PLUMB CCH — F Sw i LIC INSEDCONTRACTOR'S DECLARAfI Job Description OO z E+0 1 hereby affirm that 1 am licensed under provision, f Chap a,9("nour cin. F�C.wa with Suainn 7(11IR1 of Divisinn3 nfthe Rukber,, larnfecsiom Cr andmylieemse Is in roll tnrcc unJ cd.? (` a 1.ian.e clan. J Lie.a_ COPPER REPIPE. x o a.F Date 3*� .�j conlna,n – +� w 3 u.,� r nxclt1I4C1'•s IntcLnR, 'I v P(„�b,� C a.0< 1 nm)cnnnd nr rmn��haB rte n.cd as pnbhc mcoN. w•�p hiccnscd Ymlcnsional ea OWNER-BUILDER IIIiCLARATION el M to, 1 heoby off inn..Ina I n p,re1'mn.flit,Co dnaaar's Licerw Low rnr the hollowing reams.Section 70313.Bt inns and Pron,,ion,Cole:Any city nr county S F G which«quireo a permit to comtnmt ulmr,improve,demoli.h,For repair any•tmewrc rai Cam prior to hs ism:ma,A...require"Wilppll'unt lorsuch'lourat(olRe a dgned.":demenl thathe is licensed pursount to the p,avisnm.of the Container,License Law(chaplet 9 Sq. Ft. Floor Area Valuation pro rein,w.III Stan Ighoof Doi,ion 3of the Business and Profeeaionn Code) I,,ded his car III thi..r and the basis for the alleged a alf,don.Any vielon of Semon 7031.5 by any applicant fol.Pomo,subjers the upplicam m a civil penally of nafim.rc(him five humheddalhns(SAa1). APN Number Occupancy'type 01.aa,rvnerofthe property,or Illy employers with wages as their side cuntpenca,ion. Otifh will do Ilse work,and the sma one i,nut uncorked a offered rot lute IScc.71,44, `- Business and lhnfecsion,Co acense Code: Contranr's Lilaw,does not apply For an Required Inspections w r of property Who huild%nr improv..therwm,and who docs such work himself or through 1, is own empluyeca.privNod(bar inch mmmvenen,are on intended ur 202 — UNDERFLOOR PLUMBING . offered for Sala If,however,the building or improvement is sold within one year of inmplalimn mcawrc,thrimer,w ill have me burden(if proving that he did not build or X01 — ROUGH PLUMBING mprove Fort'an"we of kme.)L ❑1.toowncrtrill ep..... t”.our aaata,ivelyemnnleangwith Banwdcontractors m 02 — FINAL PLUMBING ENERGY construct the reopen(see.Two.Btsiaess and pmre..too,eodeD'rhe Lantmenr's 7 — FINAL PLUMBING License law docs not apply nr an owner of property who builds or improv%Bacterin, and who conlocl,for inch No',ets will,a oarnamr0) rmcoscd .uduart an the ' contractor,Lian.e law. ❑I ant corolla under Scc. .B&1'C for this tenon Owner hate WORKER'S COMPENSATION DECLARATION I hctchy unionmaiJct peealty of p jury one..(the fallowing declanJom^ , ❑ 1 have and will ntain corollate of Consort for xlf-insure far Worker's ,g I Compemation. its provided for by Section 370K) of the Labor Code, fill the pedimname of the work lir,which(bis larntif i.o,tord. ❑I have:nd will naimain Wnrkcr's Co..i,malion le,mat cc,as required by Scrim •✓ • .� 3700 of lite Labor Code,for the poll an" of the work for whldt thin Penni,i, iso ,it sly"'oder,Compensation Insurance c and''ppollVi'Je numbera are Coni r. CE-e N F1CA�nO.N OF 13XEh1Pfl ^e FRO1N'ORKIiR1' I " (46A'L(ekyCOMpENSAI'[ON INSURANCE (this section need not be completed if the permit is for one hundred dollars (8110)or IcasJ I ecrtify that in file performance of the work for which,bis permit i.issued,I shall nm employ any person in tiny mato,, ,,nom Free nme-uhjea in In,Workers' compensation laws of Ca romia.Date APPllctint NO)ICE9'0APFLICANT.11:afler(nuking this Cenilicale(I1 Exemptinn,You should hsome subject u1 the'Voder,Cral..tlon provisions of the Labor ChM,you mint Q O Iimhwida enmply with such to.ov..ionour 1111,pe if shall be declined ra,okcrl r CONSTRUCTION LENDING AGENCY ' I booby union(hill then is a con.lmaion Imtdmg agency In,the pernmaanec fol ...the work for Which this porton is issued(See.oar.Civ.C.) O. 0 Lender's Nnno Z Lender',AJdre,s U 0 1'coil,that l lon"ne I 111,uppll'atlon and lam Thal the ubuvc Infomtmion is Iz (..I enunion.I agree to comply with all city and county urdi...so and.ante laws refuting Q C.1 to building comltuction,and hereby nntherire representatives ofthis city to enter upon the ors vw...rad ancd......tiny for inymYiun purpuwn F y lits)agree to save,indemnify and keep Imi the City of Cupeniw again" V) Iiuhllitim,judgnwn,s,costs and ex.crws which nay in any way income against said U G City in cons quctac of da......Ingot leis..coot. �^ APPLICANTUNDBRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedb �4 DateJ�� SOURCE REGULATIONS. Signature of ApplicaWConmcm, [)ale R, roofs HAZARDOUS MAniRIALS DISCLOSURE. Will the app! or(lean building,*'evpam anrc orhanJle IuvuNous inertial Typc of R 1s deli tied by the Cupertino Municipal GNe,Chapter 9.12,and the Health and Safety Code.Scotian 23532(all' E)Yes GNo All to s shall be inspected prior to any roofing material being installed. Wiif the upplion",or I uturc buildingoccupunl use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove mnit hazardous air contaminants m defined by the Bay Area Air Quality IvEmagemcr, Dikmea7 all new materials for inspection. Applicant understands and will comply with ClYe, DNo all non-point source regulations. I huve rend [at bueurdous m.1,6al......rentonas alley O up"h,9.of the Cali fomia Health&Safety Little.Sections 25505.25533 and 25534.1 understand,hal it the ht"It ng dues not cunenaly have a an:mt,than a is my responsiniltry to mildly the occupa of c rc i nenls which muss be tact prior to Usuanm of a Cunilicme ill >` C 1�( Signature of Applicant Date own—rmamnan, enl Date All roof coverings to be Class "B" or better OFFICE