00080057 CITY OF CUPERTINO PERMRNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:
SANITARY NO. AP PLICATION SUBMITTAL DATI
1151 ST-AFF-9RD PR 00080057
OWNER'S NAME:
NIC CONiHOLn
40 ka
3ONC: CLEAVER DONALD W AND EARBARA A ❑ 08/08/2000
ARCHITECT/BNGINEER BOLDING PERMIT INFO
10000
&L
F6i
LICENSED CONTRACTOR'S DECLARATION
Z 0 vwi O-O I hereby affirmNu 1 em licensed under provision of Chapter 9(commercing Job Description
Fyk j wifhgecrmand.ffim,vision3mlthe Busimu and Rm(essimu Code,and mylicenme is
Y%J in full force end CRCCI.
E:,4-6- Llcenaaam Conn REPLACE WATER ?ET R
3 a y Dam
C g Contractor
O ARCHlIECTSDECLARATION ARATION
5 y 1 undersand my Plan shall W used as
public incardx
c.c..z Ccmed Professional Q
OWNER-BUILDER DECIARAIION /
I-Y r I hereby affirm them I am exempt from the Contractors License taw for the
On
f F follawine reason.(Section 7031.5.Buvtuas and RMeviaos Cade:Any city or munry
3 which".ins a permit m cmwwet,alfa,improve,demolish,or-Pim any mromme Sy. Ft. Floor Area Valuation
prim to it isananse.also requires the applinm fm mch Permit m Ole asigrcd alatemrnt
Nat he is licensed purew'n to the provisions of the Contractors License taw(Chapter9
(commencing with Section 7")of Division 3 of the Buthems and Profesaiom Cods)m APN Number Occupancy T .�wemn
tNs he is exempt therefrom and the basis for Ne alleged exemption.Any violation of P y %R.Yaa,O
Section 7031.5 by any applicant fora pmNt reboots the applicant to a civil paulry of
of mom than five hundred dollars($500).
01,Wownerofthe prcpcny,in myempluym with wagcan Weirml<cmnpewtimn, 3620C.&OV 16Inspections
will clothe work,and the structure is not intended in oftcreG for snde(Sm.7014,busineu
and professions Cade:The Contractor's Limm,law dm'ur apply to m mimes aI
property who builds or improves thereon,and who does such work himself or through 11216 - SEWER & WATER
his own employee.provided TMh
Ross such nprwmrnmnd
eu me l inseed or oRertd for
We.If,however,the Wilding or improvement is mid wnhinnne ycar.(completioq the 202 — UNDERFLOOR PLUMBING
owns-builder will Mss du Wrden of Droving that he did nm Wild rn improve for qv- .
pr�mfo"e') 301 — ROUGH PLUMBING
0 I,u owner,of the prop•ty ern exclusively contracting with.caned coeuacmrs in
construct the proieet(sm.7B14,Rosiness and Fmfndms code:)TM conummes u. 302 - TUB & OR SHOWER
room taw does rut apply to m owrcr of property who Wilds Or improves thereon.and
who contracts for Non projects wish acommmorfa)licensed pursuant tothe Contmnmta 502 — FINAL PLUMBING ENERGY
LlemsoLawexempt 506 — GAS TEST
Li i am Laempt undk er Su. .B P C fm Nis rtmm
Owner Date 507 — FINAL PLUMBING
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury mm of the following dim mutism:
1 have nM will maintain a Cenificafc of Co.'1.aclf-insure for Worker's Contact'
union,as provided for by Section 37M of the Labor Code,for the performance of she
work for which this Permit is issued.
0 1 have and will maintain Workers Compensation Insurance,ex required by Section
3700of tho Labor Code for to Perfomtantt of the work for which this permit is named.
My Worker's Compenmlion insurance comer and Policy mortar ace:
Carrier: Policy Nu:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ucIbm need Intl bocomDlned ifthe permit is formic hu.Aed dellen(SIM)
or lam.)
I certify WI in the performance of the workfor which this prism,is issued.)shall
on,employ my peon in my manrcr m or to httame subject lm the WmIxene'Compm-
action Laws of California.D.
Applicant
NOTICE TO APPLICANT:If,aft.making this Cenificata of Exemption,you should
become subject to the wmices Cwnpenulion provision.,of the labor Cade,you mum
forthwith comply with such provisions or this psonit mall bo deemed invoked.
CONSIRUCITON LENDING AGENCY
0 I hereby aim that there is a construction lending agency forts pe^amwce of _
z the work for which this permit is Issued IS.,3097,Ci,C.)
Fa Leaders Name
a ' feeders Address
tg; 01 entity that I ave nod This applimlitm and sale that the above infomwton is
comm'.I agree to comply with ell city mrd counry cadmium,and sure laws relating to
Z buildingcovlmNon.and hereby authorise repmerna Ives f'his cilyto ems,upon la
V abovememioned
Property for inspection purpous.
(We)agree to some.indemnify and kap hamulus the city of cope^Ino against _
Q V liabilities,judgment,cosi and expenses which may in my way accrue against mid City
} W in comequmse of the grunting of this permit.
t•' 1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POIM1T
ljSOURCE REGULATIONS.
Signature of ApplimoosComotm Due
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant stone or handle hazandaus material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Subtly Type of Roof
Code,Secure 25532007 yP
❑Yes Otho
Will the applicant or Wilding Occupant use equipmcm or devices which All roofs shall be inspected prior to any roofing material being
ap
emit hanndous air conionjunta as deOrcA Management the Bay Area Air Quality Magement installed. If a roof is Installed without first obtaining an inspection
^°"❑Y No I agree to remove all new materials for inspection. Applicant
❑
Ihave realtheazardousmatrialaregd'mnmtmde,Chapter6.95aftheCali- un erstands and will comply with all non point source regulations.
roma Health R Safety Code.Sodom 25505,25533 and 75534.1 understand that if the
Wilding tinea not currently have a mount.than it is my m,pmuibiloy no mwtJy the occupant
of the onnom ems which most be met poor lac wa.m a of is Cenfficme of Occupmcy.
Signature of Applicant Date
Owner or authorized gent Dau
All roof coverings to be Class"B"or better
OFFICE