02090064 CUPE
CITY
I B I DN.G DIIVIISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
AME APPLICA A E
64
PHONE: SANITARY NO. CONTROL NO.
WARCHITECnENGINEER: a BUILDING PERMIT INFO
g w p BLDG ELECT PLUMB MECH
�« L7 r-'-I f'1 1=1
N i LICENSED CONTRACTOR'S DECLARATION Job Description
J Z_G I hereby affirm that I am licensed under pro,isi.ns of Chapter 9(commencing P
mtm with Section 7000)of Division 3 ofthe Business and Professions Code.and my lienee
iyy' is in roll force and effect. REPIPE AND WATER SERVICE
e m a License Clercs Liu.g
S 3 v Dae Contractor.
ARCHITECT'S DECLARATION
aI undenund no,plans shall W used as public records
a O Licensed Pmfrssi...I
OWNER-BUILDER DECLARATION
I hrreby afmt chat 1 am u,omon from the C.nwcmr's License Low for the
C? following mown.(Section 70315.Bminess and Professions Code:Any city or county
$F r] which requires a permit to conswa,aIle.improve,demolish,or repair any opine um
ou 3 'pn. to i I .y the applicants for such permin t fl signed smoncent _ _ 3.0A 0..
. ...........
matKablimnsiedp tIo lhiiiovisiorsofineComactorsLa Law(Choral S FL Floor Area , Valuation
(commencing 'thSection-7000) 1(1 son 3 ofthe Business -
and CWrJ t r s9't J , VL
or that he is exempt mererrom and the basis for the alleged esempu.a.Any violation '3 1 6 3 5 17 , 0 0 '
-of S«tion e than by any hundred
am fm a permit subjttts the applicant w a<isil pcmhy APN Number
of net more man five honored dollar ISS00). � " Occupancy Type
❑Las.wnrr of the prop=ray..r my rmpl.y==s won wages as mebwlr=.mp<nsati.n. 202 - UNDERFLOOR PL MBING
will do the work.and he someone is nos intended.r offered far sale(See:]OLJ. 3 01 - ROUGH P p�[�
Business and Professions Code:The Contmnor's Licenselaw does not apply to an MMSpection$ l " '�"'I r
caner of pmpeny Who builds.,improves them..,and who does such work himself 502 - FINAL PLUMBING ENERGY
or through his own employees.provided that such improvements are not ne ,intended or
-,o6nipl m.,,he.own,bold,tnell ilamgrburde.�emro in sola withinoneyear., 507 - FINAli PliUMBING. . __... .- .- .._._ . .......... _ .. _._ _._
completion,the owner-builder will hate the burden of proving that he aid not Wild., ' ' '` '
improve for purpuu or sad,)
1.asowncrtil the n.amexclusivd Irani. .. .. .. . . _ .. ...._... ..._. ._ ..__.._ _....
..._.. .... ..._ __ •__.....
prop. Y and I g with licensed commracts m
onswn the projen(Sec.1ta an Business and Professions Code:)The Contranor's t..I: 1 st•,q
License law tract not apply man or,of a conty who Wilds seimproves Hereon,Contractor.,
o h t enscts for.such P J t wnh mracmds)hccnud.pursuant m He .. _ ._. .. .... ........ . . __ ...._.._ ,(k q
Cram t License W
JAN " 7 003 ... _ ....
❑1 pt acr5 � ; '"� � � ,B9PC for Has reason
4� ry t<ER'S NSATION DECLARATION BUILDING
1'v IAI^
�LD
! Ih by affirm d penally of pegry fthe falwin%dedarations: AV VI
I{ O I hoor and 11 m ratan..6rifflune of Corserz to self insure for Worker's
\\\\
Compensation. a. pro d d for by Section 17M of the Labor Coda for the
pedmooricc ofthe work for which this perm) s`ssued.,
❑I hats and will maintain Worker's Compc nation Insurance.ai required by Section
- _ 37W of the Labor Calc,rot me,performance of He work for which this Permit is
I, ed My Workers Compensdtlon'Inmcance.airier and Pnlicy,nbin reye:
.. Camcr Policy
sIC CER11MCATION OF EKEMP ION FROM WORKERS'( ,` t s a\ Vs s ) ,a`a °a s .1 ) ;v, I
COMP.ENSATI, _
..., ,. .,...,., ON,INSURANCE,. . ... - _._., .. - .._ ......._. ._ ..- _._..,.. .._._..- ._. ...........
ITh ton Tied t be completed f thepermit is for one hundred dollars - 1,'.. . . k 1 - - -
ISIUO) .I 1 ,
- issued
- .. ...
cent fy tht .the performancent thework for huh this perms srcsuedl
shall of to y pc mann t'become 5ybg d to the Workers'
Compen t fir, to tZ-O C
.Apprlr t . . _ _. ... ._- ..
E'IU APPLICANT If, fter making th
Z C-enf t fExemption.You should
Wobject 1.the W k C p alpLabor sons o .you must
Z Q Forthwith< py with such psons or s Permit shall Wdeclined rev.ked.
s
of the work for which hl
CONSTRUCTION LENDING dAGENCY'
f the - -- - _ - - -
h,
0. A pcnnrstsiued(Sc 3W1,Cl,CJY ..... _.._ ..__._. ..__ .. ..__ _.._.._.-_ _ _.. ... .
rfoim
,7 Z lend- Addmu
U a.
,el n ry,m t 1 have ad this application and stale that the informationn is
�+'[.. crirrcc.,I agree m comply with all city and county ordinances and state laws relating
'O.V so ifiingconswction.andhembyauthorize'repmuntativesbfmiscltymentuuWn
,j. W the above-mrribmed progeny for impeaion pmtpvus.
►-.IL (we)airee to save,indemnify and keep hamless the City.f Cupertino against
Vg Iiabilities,judgmenls,costs and expenses which,may many way a=ctor against said
V Z City in consequence of the gmming of this permit -
APPI 'NDERSTANDS'AI:D WII CCOMPLY WITH ALL NON:POINT Ddle /
S sat 's. n Issued by
ALP
Applic ter to """:` - Date a-roofs
HAZARDOUS MATERIALS DISCLOSURE -t."
Will&applicantorf twc WiWtnB�oac Pa t smum.nawl hila .smaterial . Type of Roof ._,_...;. .. .. _. . .
as def cd by the Cupen o Mon opal Cod Chapter 912 and me Health and Safety ,_, -
Cade Sceu n 25532(u)' • i - • p I! k ". s 1, t ,, t . g • .
❑Yes ., DiQla
'r L "' ,:11.. ! t
All roofs shall be inspected prior to.any.roofing.material being installed..
Winthe applicant or future building occupant eBayAeaAip Qm.tyMandevices whichgement If a roof is ilis[alled'without first obtaining an ins ection;I a ree.t0 remove
Admi emit hazardous air contaminants as defined by me Bay Arca Ate Quality Management g P g
DisricR /
all new materialsforiinspection.. Applicant understands . _ _.will comply.with
Y� and w
Q all non-point source regulations. .. tl,•
I M1 e read the M1 rue, i 1. req 25533 a uncle Ch pt r 6.95 of the
Califf m Health&Safety Coag Seci ons 25585 25533 and 25514 1 undcrsmnd that
iQhc htlding dnesnaurreonly have a tenant.that it is my responsibility m notify the -- - - -
an of He rtqu'emend which must be mct prioi to ismance of a Cenificae or ` ' -
"" Signature of Applicant „ _ _ Date. - - _-
what.taaH.m:raagent" .'a" - Data All roof coverings to be Class"B" or better I' '
OFFICE
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