02110144 (2) CITY OF CUPERTINO `
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION
Bull.21231DIFsFiANICE AV ALL VALLEY PLUMBING PERMITNTg2110144
OWNIRVA*G ZIGURS 170 BRANNON DR AFPLWATRINTI625FI2002
iONI 510 3 7 6-4 816 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
0 0 0 0
r00 LICENSED CONTRACTOR'S DECLARATION �p
p I hereby affirm that I am licensed under provisions of Chapter 9(commencing WATER HEATER I�MeM!LftiqT
t5j with Seni,,nlll*lof Division3nf c Busineaaand Profesai ns Clwl��cyyand mylicenwis
w
mm",lull lime and effect y v
License Clot' Lie.X s
Oal-b Dam - Ito, s
nt- RCI FFECI"S DECLARATION
l ondcr. J my plans a be usce as p 4lic records �((,(/Iy�6/q
CLL OWNER-BUILDER DECLARATION
u� 1 berchy affirm that I ammexempt from the Contractors License Law for rhe $700
w-a O f owing reason.(Section 7031.5,Business and Professions Cole:Any city or county
s $ which requires a permit to consuwL alms,improve,demolish,or mp or any Rmemm
prior to its issuance,also mumas the applicant for such permit to file a signed imminent Valuation
p�pm�m<
that he is time nsct pursuamtn the provisions of the Contractors License law f&pmr9 ��.I�.�I' ]bBAf��
yF� (commencing with Sectio 7000)of Division 3 of the Business and Profcasions Code)nr
$ that he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penally of N-NPLUMBiNU eeupancy,Type
not more than five hundred dollars($500). CJO6 - GAS TEST
❑Lu owner .the propeny,or myemntendes with wagoaaNei((See
cram,Business
will do Ne work,and theswcture firms intended...ffered for sale(gee.]014,Business
and Professions Code:The Contractors License Law docs not apply to an owner of egwre nspections
property who Wilds or improves Ncmon,and whodeassuch work himselfor Borough his
own employees.provided that such improvements art not intended or offered for ale.If, _ -
hawver.Use Wilding or improvement is sold within one year of completion,the owner- Ln \
builder will have the burden of proving Nat he did not Wild or improve fur purpose of
sated.
❑1,as owner of Ne property,am exclusively contracting with licensed contractors toconstrue Nees not (Sec.71�toan Business and rty whoions Code:i Tho Com hereon,Lidcense whoconwdocorsuchplr lean ithawner omommny who sedpurslds oruattothe Ncmon.and
who contacts for such projects with a enntracmr(s)licensed pursuant to the Contractor's
0 1ive..Lew,
❑ r
1 am excmps under Sec. .B&P C for this rtaan
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will mainuin a Certificate of Conant m aelf-insure for Worker's Compote
7700
ion,as provided for by section 37M of the Labor Code.for Ne perfom rmce of she
rk for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,fnr Ne performance of the work for which this permit is issuedWake'a rmpensatio nambec carrier and Policyn mberam:rticr Policy No.:�
CERTIFICATEOF (EMPTION FROMWORKERS
COMPENSATION INSURANCE
mussecrion need not becomplcted Kthe permit is formai hundred dollars(S ion)
less.)
I certify Nal in Ne performance aide work for which this permit is issued,I sh ll not
employ any person in any manner u,M or become subject o Ne Workera Compensmion
Laws of California.Dale
Applicant
NancETO APPLICANT:I1,a0cr making this Ccnilicam of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
O ,Z, forthwith comply with Such provisions(it this permit shall W deemed revoked
z O CONSTRUCTION LENDING AGENCY
Ew wNsr I hereby storm that there is a constructions lending agency lot the Performance of
y 7 tbe wok for which this Permit is issued(Sec.W.Cie C)
{A Q Lendcri Name
11 lenderi Address
OU 1 comfy Nat 1 have reed this herin rept and ante that Nc above in ice upon is
H correct.l agree to comply with all city and county ordinances and state laws miming to
V ime--mendoned ogand hominy awhoriacrpoisoy for inspection posescmalivcs of this city 1c, nice upon rbc
s.
(Wo)agree to.eves indemnify and kithmay
inharmless Nc City mCupcnst against
C43 Iiabilifics,juJgmen6 costs and expenses which may in any way seism against aid City
V in consequence of the rating of this permit. l ` O
�+ APPLICANT UN STANDS AND WILL COMPLY WITH A NON OINT Issued by: Date /"Z
E REG IONS.
® Re-roofs
at of ApplicantlConwflor am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building=Upon[store or handle hamodom material
defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section zsslz(e)7 All roofs shall be inspected prior to an roofing material beim installed.
❑Yes Sir P P Y g g
Will Nc applicantI or ulurc building tmcupnm use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
toll hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Xk
I have mail the ha ovors materials requirements under Chapter M1 95 of the Califon
niallcdh&Safmy CoJe, dons 25505,25533 and 25534.I andcamnd Nu if the Wilding
m,. if hew nanl,dust it is my respossibilily m redly therccu al of Nc
® require emxwhlch IN.,IPrior ri anccnfeCcniF, wof4�pan Signature ofApplicant Date
sen r tmeriedagent Dale All roof coverings to be Class"B" or better