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CITY OF CUPERTINO
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CONTRACTOR�INF,ORMAT'ION:
BUILDING DIVISION PERMIT
. �I
BUILDING ADDRESS:
TOM'S PLUMBING
PERMITNO.
21089 WHITE FIR CT
OWNER'S NAME:
12246 SARATOGA SUNNYVAL RE
APPLICATION SUB DATE
NANCY CANTER
12/17/2002
]ONE:
408 867-6010
SANITARY NO. CONTROL NO,
ARCHI'IECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hereby affirm that 1 am liccned under provisions of Chapter 9 (commencing
with Section 7006 of Division 3 of Ne Business and Prnfcssions Gale. and my license is
in lull lime and effect. pp��ppp/
REPLACE WATER HEATER
Liccae Clan=1-0r-so—
Date_ Cnnl[vv Inr
ARCIII'IN ,
interior records
I understand my plans shall be uuJ as pts s c Js
p
Liecnvd Pieft. ignal
OWNER -BUILDER DECLARATION
I hereby Million; that I am exempt from due ConImc1011 LIcemi, Lw, Illr the
following reason. (Section 703 1 S, Business and Professions Cock: Any city 0, county
Which irrupt, a pundit hr construct, alter, improve, demolish, n, mpair any slrwmre
prions its issuance, also [cgmres the applicant for such permiuo filo a signed statement
Sq. Ft. Floor Area
that be is lice noted pursuant to fire provisions of the command Lice rim Law (Chapter 9
$39ftation
(commencing with Section I OXB of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
Occupancy Type
Section 7031.5 by any applicator for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S50B.
El I,..., of Ne pMp m , or my employees with wag. as Neu role compensation.
502—FT NAtty
quire nspec rods
will do the work, and thesoucws is not intended or offered for sale (Sec. 70H4, Business
and Profession Code: The Co..,., License Law does dol apply to an uwrter of
5 0 6 - GAS TE
property who (wilds or improves thereon. end who docssuch work himself or Mmugh his
Own employees provided thats9ch improvemen¢ amnot intended reoffered formic. If.
507 — FINAL PLUMBING
however, the building or improvement is mid within one ysar of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sake I.
[D 1, as owner of Ne property am exclusively contracting with licensed contractors In
FI N A LE
construct Ne pmject (Sec. 70,14, Business and Profession Cote:) The Convenors Li.
cense law does not apply In an owner of properly who builds or improves domain, and .
who contracts for such projects with a convanor(s) licensed pursuant to the Contractor s
DEC 3 0 2002
License Law.
[3I am exempt under Scc. B & P C for this reason
Dara
WORKER'S COMPENSATION DECLARATION
BUILDING
I hereby allirm under Penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent In self-iname for Workers Comtism
orer, ax provided for by Section 3701 of the labor Cruse. for the performance of the
1wn,r
ork 0r which this permit is issued.
1 have and will maintain Worker's Compeosafion Insurance, as required by Section01
of the Labor Code, for the peRnrm muse gf the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number am:
rtier: Io,�wy= /L•• U �4skK Policy No.: &W —0 yf i�i:a� O
=1`1
CER'IFICATE OF ION FROM WORKERS'
COMPENSATION INSURANCE
('This section need nm be completed fine Moril is for one hundred dollars (Slap
n Icss)
I certify Nat in the performance of the work for which this permit is issued. I shall not
employ any Person any manner so as In heenmesubjoet to the Workers''Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: 11, alter making this Ceni mr, of Exemption, you should
become subject m the Worker's Compensation provisions of the Labra Code, You most
forthwith comply with such provisions or this permit shall be deemed revoked,
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency or the performance of
the work for which this Permit is issued (Scc. RN7, Civ. C.)
Lender's Name
LenJci s Address
1 certify Nat 1 have read this applieaaon and some that the above infonnalfnn is
correct. I agree m Comply with all city and county ordinances and some laws relating to
building construction, and hereby authnrire representatives of this city In enter vPon the
abnVCRlCe)agedproperty for emnifyan keeph5.
the City Of Cupertino against
(We) agree to cove, indemnify and kith hayin
a
judgments, costsand expenseswhich may in any way eceme against said City
in consequence SI CC of the granting Sthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'1'll AL1. NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
104,711 L
. gnamr fApplicamlContraam Uate
I IAZARDOUS MAI T?RIALS DISCLOSURE
Will the applicant or future building tweupant store or handle mrmdml..led.]
as drained by the Cupeni or, Municipal Code. Chahar 9.12, and the Ilealth and Safely
tale, Section 2553200?
All roofs shall be inspected prior to any roofing material being installed.
p Ycs 5 N
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant.1futurebuildingOccupantuseequipmentordeviceswhich
emit haanrdoua air cunwminerm as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
E] yr., %IlnNo
I have read the ha.zrdous materials requirements under Chapter 6.95 of Ne Caldor
nix l lealth tit Safety Cad, Sections 25566,25533 and 25534. T understand that if the buildingz—
doexnotcurremlyhawatenanl. that it it MY wapoaaMIUY to notify the reclved of the
r
requirements which Must bemet poor toissuance ofaCmifieataorOccupancy.
nature of Applicant Date
All roof coverings to be Class "B” or better
0wnerflfion.magent Q„eI