04010120 CPI'Y OF CUPERTINO
BUILDINGDIVISION PERMIT CONTRACTOMNFOI2MATION _i
B ILDINGADDRESS: CLEARWATER PLUMBING c PERMITNO04O1O12O
914-Al r0T.UMPTjS AW
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO, CONTROL NO.
ARCHITECi'IENGINEER: BUILDING PERMIT INPO
BLDG ELECT PLUMB MECH
0 0 0 0
U0, LICENSED CONTRACTOR'S DECLARATION
FF 1 hereby affirm mai 1 am licensed under previsions of Chapter 9(Commencing Job Description
iW with Section 70'abofDivim3 fmc Busincayas +mfeasiuns Code.and my hccnu isA. I I�fl
inmuseC1 a iRect� 0 I�Btl��p rte®
;q ucenxeL7 L•-'ib Lie.a 719'tJG WATER SERVICE bLl'4`i'�L,�
gFp Date / /—]S-nc— Conlractor[ � r
l� ARCHITECTSf�, j'pRATIDN
# understand my plans shall W used gfpuhlic rcemNs JAN 2 7 2004
>dD
10 Licensed Pmfcssional
e g OWNER-BUILDER DECLARATION
<P 1 herehy affirm that 1 em exempt from me Commeon's License Law for the '���x� Q'9�t�l�s}�
po following mason.(Section TID 1.3,Beat.,and Professions Conde:Code:Any City Or county ., nn NG
K m f which requires a permit to construct,alter.improve,demolish,lir repair any structure
poor to its issuance,also requires the applicant for such Permit to file aligned.nammenl
<
that he in licensed pursuant to the previsions it(On Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
Ar (cam meneing with Section TOIXI)of Division 3 of the Business and Professions Code)or
i $ that he is esempt thcrcfrum and the basis for On alleged Cxemption.Any violation of
Section 7031.5 by any applicam for a permit subjects Or applicant to acivil penalty of 391TN4'6"grO0
not more than Eva hundreddollars(15o). Occupancy Type
I,as owner of the nursery,or my employees was wages as their sole compensation,
will do On work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Ccdc:The COBaaCmrx License law does not apply to an owner of Required Inspections
property who builds or improve thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement is sold within one year of completion.me owner-
builder will have the burden of proving that he did not Wild or ire prove for purpose of
sale.).
I,Bs be,of in.Pim"ty,Om exclusively contracting with licensed Cm.mrs In
construct the project(Sec.0044,Business and Profusions Code:)The Contractors Li.
cera,law dont not apply to an owner of property who Wilds or improve demon,and.
w ocontracufor such pmjcm with a comraclor(A Contractor's
pursuant the Contrac
Co.Law.
1 ore exempt under Sec. .B&P C for this reason
40 consone"
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations01 :
❑I him and will maintain a Cert;fieale or Cometh to self-insure for Workers Compen-
sto on,as provided far by Section 34W of me labor Code,for me pesfnnnancc of the
work for which this permit is issued.
(]1 have and will maintain Worker's Compensation Insurance,as required by Section
30W of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Comlcnsallon Insurance canter and oli number are: -
P
PCERTIFICATE OF EK EM MO OM WORKERS'
C
COMPENSATION INSURANCE
Rho retire recd not W compleed if the Intuit is for one hundred dollars(11 W)
or less.)
1 certify that in the Performance of the work for which this Permit;s issued.I shall not
employ anbreraegja any manner-an As On tbecume>� to the Workers'Compensation
Law of C Data ,C
ApD ca t
N TO APPLICANT:IL after mating Compensation pr visi ns of of Exemption,you should
su omp to me worker's ons ortsprovisions of me CoedLabor Code,you most
.JO forthwith comply with such provisions or this Permit shall he deemed rcvOkctl.
Z CONSTRUCTION LENDING AGENCY
[-. Ihereby affirmthat them itsconsametionlending Agency Lot the,perfoma<or -
x 7 me work for which this permit is issued(Sec.3(19],Civ.C.)
0 lender's Name
Lender's Address '
D
U 0 1 Certify met 1 have read this application and suite mat the above information is
ry F coned 1 agree to comply with all City and County ordinances and slate laws relating to
DU building construction,and hereby authOhM mfocaentatives of this city to enter upon me -
alwve-mentioned Property for!."don purpous
Fy (We)agree to cove,indemnify and keep hay in an the City mCupenst against 1 ��
f. liabilities.judgments,costs i and expenses which me may in any way simmer CApen um against
City
U in consequence or me graming of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
mnawrc of ApPl'C HAZARDOUS MATERIALS DISCLOSURE actor Deese Type of Roof
Will me applicant or future building occupant Store or handle haardous material
as donned by me Cumnino Municipal Code.Chapter 9.12.and the Health and Safety
Code.pir:zss3z(a' P All roofs shall be inspected prior to any roofing material being installed.
Will the a licantor future buildln accts ant use c t or Jcvices whicM1 If a roof is installed without first obtaining an inspection,I agree to remove
nP s p quipmen
<mithaamnosalregammmantaaxdefinedbythe Bay Area Air Quality Management
. . all new materials forinspec[ion.
District}
❑Yes Nu
I have read the Waamous materials requiremcros under Chapterti.95 of the Califor.
ria Health&Sarcty Codi,Scctiom 25515.25533 and 25534.1 un Mand that if the Wilding
dens not currcully have a Conant that it is my m,,msihility In rdLil,me maupanl of thc
requlmments which mot W met prior to issuance of a Cerdficaut djAcupstacy. Signature of Applicant Date
aAll roof coverings to be Class"B" or better
Owner or aumunled agent Dam
CITY OF CUPERTINO
S REPIPE/SEWERS/MAIN SERVICE
CITY OF
CUPERTINO PERMIT APPLICATION FORM
0�0 /l/ad
APN # Da�t(
Building ddress:
Owner's Name: Phone#:
�. N
Contractor: Phone: License
75
Contact: PhoneC rtino Business License #:
sc-
Q
Building Permit Info:
Bld Elect ❑ Plumb
Job escnp ion•P.
L.IC 7 SLrvtGY
Residential Commercial ❑
Cost of Project f y yo
•
Qty:
A c 1 Fee ID Fee Description Fee Group
PPERMTTFEE Plumbing Pennit Issuance PLUMBING
BPREPIPE Revive of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Dis osal PLUMBING
BUSLIC Business License BUILDING