03110031 (3) CITY OF CUPERTINO ' 7 ''
BUILDING DIVISION PERMIT tCONTRACTORTINFORMATIQN '"
BU I LDING ADD KESS: r PERMITNO03110031
642 LARRY Wy
t •
OWNER'S NAME: PERMIT ISSUE DATE
DONALD FOULGER —. .11/06/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
p0 0 0 0
1
00 LICENSED CONTRACTOR'S DECLARATION
I Mreby affirm that I am licensed under provisions or Chapter 9(commencing Job Description
with Section 7=))nr Divisio o(dtc Uusinr3s enJ Professional Codc.and my license is
mr.11 �aa�qp!dffee C �[J [ SEWER LINE
jg? Lic CIaS' CR!p v �
-to D e_ A ITEM
CONTRACTOR: QUICK PLUMBING INC
p RATION
ly aderstand laps all dos Public roc
a
,s�G Licensed PorrAmienal
,5 - UILDER DECLARATION
��;g 1 hereby Affirm that 1 am exempt from the Contractor's License Law for the
❑O following mason.(Section 703 1.5,Rusincss and Profeasinns Code:Any city lir mumy
S$ which requires a peril in conswct,alter,improve,demolish,or repair any structure,
-iy prior to its iauanee,alsu mquirostMappliean,farsueh Pcriuo fleasgned stammer,
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that no is licensed pursuant to the provisions of the Cmuracion's License Law(Chapter 9 Sq. Ft. Floor Area Valuat2000.
y3 (commencing with Section 7")of Division 3 of the Business and Professions Cook)or
x that he is exempt dwmfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for peril subjects the applicant to acivil penalty of 316&D2Qj'AZcr0 0 Occupancy Type
not more man Eve hundred dollars($500).
P �' YP
y ❑ I,as owner of the property.or my employcu wlt�wages ae melt sole eompensetian,
will do the work,and tha s,uctum isnot intended or offered from flied.71544,Business Required Inspections
and Professions Code:The Contactors License Law docs not apply to an owner of q
pvPeny who builds or improves thereon,and who does such work himmiror through his
ti own employees,provided that uch improvements are not intended or offered for sele.IL
s however,the building or improvement is sold within one year of completion,the owner•
builder will hats the burden of proving that he did not Wild or improve for purpose of
IJ said.).
a
❑ h construct owner of me property,.B sines nd contracting wire:)TheeConnvacm,la
enseLa the es not (Sec.7044,wner or end property
who Wionslds
Code:)The vas 0m ton,and
cave Law docs not apply to m owner of properly who Wilds or improves,hemon,and
whOc fur such projects with a contmetortal licensed pursuant to the Contractor's
L' n
1 er See. ,B A P C for this rtaon
wner Data - -
WORKER'S COMPENSATION DECLARATION
I hereby afRr under Penalty of perjury one of the following declarations:
I hove and will maintain a Cenl Been,of Consent m self-insum for Worker's Compere
salon,As provided for by Section 37M of the labor,Codc,for me perform¢of the
work for which this perp is oemed.
❑I have and will maintain Worker's Compensation Insurance,m required by Section
37W of the Labor Code,for Ne performance of the work for which this Petit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the petit is fnionc hundred dollars(SITO)
or lass.)
1 certifym m the perfarenee of the work for which this Permit u iamdd.1 shall nut
employ en onto t(tmTr m�ic �R bj
a ecl to tMWorken'CompenMLm
Laws of 1 role,
Applicant
NOTICPeTQAPPLICANT: , 'tc eking this Cenifcatc or Exemption,you should
become}moi ct to the Wohch Com emanon pmvisinns of tW LAMr COdc,ynu must
.'O forthwith comply with such provisions or this Permit shall W deemed mvnkcd.
Z� CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a consuixtinn lending agercy for the perfuram:e of
Z the work for which oris peri,is issued(Sce.3097.Civ.C.)
IIALcndcr'a Name
=3. z Lender'sAddress
U O I mnify that 1 have mad this application and cute met the above information is
k. !' correct.I agree to comply with All city and county ordinances and more lawi relating I.
SVS building construction,and hereby authorlm represenra,iss of this city to enter upon me
(7.1 above-mentioned property for ivpcetion purposes.
(We,)egme to cave,indcmmfy and keep harli a the City of Cupertino against
V kAlagmentscos,and expenses which may in any way accrue against mid City IT ofthegmmingthisPermitT DE AN AN ILL COMPLY WITH ALL NON-POINT Issued by: Date
AT
Re-roofs
Signature of Applicant/ tractor Dale
HAZA11111111S MATERIALS DISCLOSURE Type of Roof ,
Will the applicant ser Nona building occupant store or handle hmrdous material
As defined by the Cupenino Municipal Code,Chapter 9.13.and the Health and Safety
Aide.Section 35533(x)1 No All roofs shall be inspected prior to any roofing material being installed.
❑Yv
Will the applicant or future building becupnn,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
av il.m.us it conmminmas As defndd by tM Rs,Area Air Quality Management all new materials for insct? pection.
❑Yes
Ih mad thehma rwsmaterialsmyviromcntsunderChapmr695ofdmCalifor-
mHealth Safe Code. 5(15.35 and 25534.1 undemtmd moil the Wilding
not c Awe n rat itis y spo.,I liiy to nntlfy the -cupmt Of the
now ' must et ' itnis ccofeCc ' Ocum Signature of Applicant Date
Owner ser amborired agcnErri, All roof coverings to be Class"B"or better