01080089CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
B ,LD1 GADDR SS
591 ASTER LA
CUPERTINO PLUMBING
PERMIT NO,
01CC0Pf80089
S ATED AND EVA
10297 S DE ANZA BLV
08�T7,T�6A01
PHONE:
(408)253-0618
SANITARY NO. CONTROL N0.
Z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
m
CJ LJ LJ L_I
i LICENSED CONTRACTOR'S DECLARATION
Job Description
O _ IM1erebyaffimvhalamlicensedunderprovisions.TonsCde.andmylicese
COPPER REPIPE.
hh Seciion ]000)of Ulvision Sof the Business and Professions Code. and my license
Is m hill force and¢t2/ ` [�p t�
y
ime Class V Lic.# tPzyYo,
F Dam it7T Camractor' 2Je0.t,-y—
�'—
RCCf'S DECLARAT N J
1 understood my plans shall be uzad an Public records
-
O Licensed Professional
OWNER -BUILDER DECLARATION
To I hereby offina that I am exempt from the Contractor's License Law for the
'
G following reason. (Section 7031.5, Business and Professions Code: Any city or county
$5000
O which requires a permit to construct, alter, improve, demolish, or repair any structure
f t c t cantor me rmuo eat .ttmm
prior9 pP Pe .g
,36%42 EtOFllgor-�.�a
Valuation
- thyhe31enxdpn mtothpro'.onsoftheConvacto Lc L Chapter
moronic, ction]000) of Divumn 3of the Burnt s and Pr fid,,u nsC de)
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or that he is exempt therefrom and the basis for the allegedpxempuort Any violation
of Seetion:7031.5 by any applicant for a Permit subjects the applicant to a civil penalty
ofnotmoredimEvehundred dol...S500).
202APNi�M'BRFLOOR PL
MBING" Occupancy Type
° 1, as owner of the property, or my employees with wages as their sole compensation,
301 - ROUGH PLUMBIN
502 - FINAL PIA34E YITRs�'aAlthBiiQ'Y
an is mended offered for sale (sec:
iB11 do -thework, -and the d oro
t B cid oone Cade The nttrdinten
ode:Tstructure Com License to an
Law does not apply t0 an
aw raf,.,,,y Who builds or improve, and who data such work himself
507 - FINAL PLUMBING
or h'. employees, p d d that suchimprovementsmintended
_
"offered for 41e:1Cfi'eeglhe timldm ssold wrthnose "f-
er fo g rntpr,of yoldo
...__. .._ .._........_.. .. _..._....._.. ___....,.. _... .. :.._.__.... ....... ... .... ___
., ,
- -
ompletion, tone owner-huilen. will have he burden of pmving that he did nm hold m
Pro
imprme for purpose of sole.).
_
. �FJI a own .,of Chep pent' .. ...I s ly t m tC sed m em m
-
co t t me i
p I t IS ]04J B d Professions C d) Th C t t
L L d r ppl3 m o f property h b ild. r mpro Thereon,
..end hoc to ts.f sucM1 P"j", wmh.a. aontrachwad licensed pursuant to fie,..
... _... .. _.. .. _. _._.... .. _. _. _ _ __.
C m t L ceme lm
°I mpmuntle S H&PCfomM1ia rcawn
1.%: .• j
O e O m
WORKER'S COMPENSATION DECLARATION
' therebyoffin d penalty of pet y cf,h,fallowingdelamra
❑ I ha a and will ma cit C nificm of Consent to elf n for W rker's
Compensation; ,provided f by Sect 3700 f the Lebo Code, far the
'peA m o
/
_ f the u rk f r which thi: permit d
'Q U and will mount n Workers Compensation 1 wmn a required by Section
370 the Labor Code, f the performance of the mk to,which this perrat is
;s d M Worker'd Compensation Insurance chtrief and Policy numtdr are:"
MOM
N WO KERS
( B CATION OF EXEMPTION PROM WORKERSIs
COMPE
COMPENSATION INSURANCE
_ _ ..___..
..I
t obs wclon need not be completed if the Permits for one hundred dollars
s-
(51007 or less.)
I cert ft' that rt pert f rah w k f r eh t s'is I'
i :,+ ,
e a u ct a
p n in any n so as id bctol a subject m the Workers
co
shall not aim
'" '
C m m 'Law's
� pensa of California. Date
l-mies
NOTICE TO APPLICANT
'becamenTOA
t the k I' L b C I, ym ust
t onsll
'fanM1wuh
ci
comply with h pmvwonx o this ami t shall he doomed rc ked I
s e
�
A "Itr "' CONSTRUCTIONLENDINGAGENCY
1 he h affirm Thai to cont m n leasing ag y f the perfen nl
�
ti Iofine rk fn hich thisR t issuedfS 3097; Cis. C)
�'-Le tiers Name r„.. _. .. .,.._ .. .gin __
..._ ... __.._.__ .. ._... _.. .._.. .. .. ___ �.. ..:.. .. ... ............ ...... ._.. _. ._... .. _.__.
ti de - Address
-/
1 i fy that I have read tti �ppl cat a n d sm t that th al information is
c'athe m 1 name to comply with all city and county mfirmaces and Stam laws relating
j Ito building conswctidn; and hereby bumorize representatives of ethic city to enter upon,
�] the abgve-memloned property for, inspection Purposes. _, , _ „
y (Wd)'agme mo save, indemnify and keep harmled+the City of Cupninb ogaina
A IibThe,.,.dgmenrs emas d ex once which may in any aI c me agai ,m said
ir CitYI 'e Tic ftleg rmM1spint
'A
C'
,tin
ND ROO SA WILL COMP LY WITH ALL NON -POINT c'
P$b i
/^701
Issued by: Date o /
Eft f
gtwt fAppl': m/C at 'm rA ., l- ., t. -Date.: �-
Re -roofs __-
HAZARD MAT ,ALS DISCLOSURE . T -
/. qll th appli t Tum rebuilding oc pani stored hndlh Nous conal
srSI e 0 Roof
']I3 of_ ....:.. .. „... ... ,_. .;. _.., -.... - _.. .,�, .,..,,,.,
a defined by the Cupen Municipal Code, Chapter9,12, d the Health and Safety
,Codes ton 2553,(1
°Y °N " I
�_
roofs shall be inspected, prior to.an r
p y oofing,material being.installed
f -
W II The a I c m tut buildingovio em e t devices which
'ch Peam
..All
.,
t
move
th mds s mmnt Jcfi by the Bay A'maAirQ alq'M nog cit
D, tr ct
all new materials for inspection.t Appl cant understands and will c0m
p ply with
:r OY • ❑No /
_
all non- Dint Source r0 Mations. rI
h tome Is menta d Ch pier eph of me
ha lth
gift
& Safety Code:
Safety Code;avea not 505, 31.1undcrstandtthe
rgjirg bar
I mains. 1, is voc',nd
-, ifm boiWing dagsnt cndvha have nmthtm" to noufy the
�
�nr.a
--
' bf tfie qi m m s icti iiun b m p for moi wnce
arTe fay Cenifcate of
O n Y
,Signature of Applicant„ _ _ _ Date
All roof coverings to be Class B" or better
e aatnon¢edage t , mm�
..OFFICE.._..._... _. ._... ... .. - -