03020070 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACyT®R INFORMATION`
v 'aN Y Y ,NFOR ah .. Oyr lc
eDIMINGADDRMS: CUPERTINOY PLUMBING PERMITNO.
OWNLA RGDA 9R
. ' A E: 10297 S DE ANZA BLV APPLEAT A
NE: SANITARY NO. CONTROL NO. .
(408) 253-0618
AR MITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
yoo LICENSED CONTRd underSDFLLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9lmmmen cess Job DCSCfIpIl00
n� with Semion 11M0)oJ�Divislan 3ofche Business end Piafes lope Crede.and mylicenso is �a����®
In full force anJ I/+ �_
0�� Licenm Clew. L tae.« COPPER REPIPE
Date convector
�e ty ARCHITECT'S DECLAR TI [s
y N 1 understand my plans shall Ir used u public retards MAR 2 r+ U �OO�
owes
3tG Licensed Professional
OWNER-BUILDER DECLARATION
C.amnu BUILDING
0 1 hereby mano affirm on 11. eBusin from the Cantons Co License Lew fur Ibe
i O o which following mason.(Section fl13 s r t,idfi u and Pndesaiuns code:Any city structure county
which rets mornpermit I.reermstht,alma improve,h NnIt t nrmash anyment
Fad,'
poor(he itscensed ,also requires theapplicantfor Cminnamlt mi a.Lawd statement -
gg (commeacingwJpSectio7fliofDivision3oftheBunctoraLicenselans;Coder9 Sq.Ft. Floor Area $5��[ion
g �
(commencing exemithSrefro an)of Divialon3 of the Business endon.Any violation
Code)or
Nn io is 31.3 b therefrom and the aper for the subjects
alleged eumant to Any l lemon of
Section any ermltsubjectsNeapplicannoetivilpcmltyof 3 �pMtgr00 Occupancy Type
nm mart Nen Ove hundred dollars(5500). ,
❑I,as owner of the property,or my employees with"Sam their sole compensation, 7,7�T Tf�A
will do chs wok ands:The unoCommencot es
Lice Law ed does notlepply in an,ramex o• 2 02 — UNDER d Yihlry 4
and do me wov code:The Canmactors tembut Law does not apply m an owns of '�7 YV•
properlywho buildsor improves thereon.and whodoes such anus himselfor through his 301 — ROUGH PL BIN
Own employees,provided that such improvements are not intended oraffemd for sale.If, SO2 — FINAL PLUMBING ENERGY
however,me building or improvement is sold within one year of completion,Ne owner-
builderwillhavetheburdenofprovingmathedidnotbuildorlmprovefurpurposeof 507 - FINAL PLUMBING
sale.).
❑I.as owner of the property,am exclusively contracting with licensed eonvacmrs to -
construct the project(Sec.704,L Business and Professions Code:)The Commit Li. - -
cmue Law does not apply to an owner of property who heads or improves Demon,and
who contacts for such pmjeca with a contractors)liamed pursuant o the Conuactoes
License Law.
❑1 am axempl under Sen. .B A P C fm thismason
Owner Data
WORKER'S COMPENSATION DECLARATION
Ihereby affnm under penalty of perjury ane or the following dsclpeatlons: t
I hen and will maintain a Certificate of Consent to se141nsum for Worker's Compen- _
tion,u provided for by Section 3700 of de Labor Code,for the Nommunce of the
work for which this permit is issued.
❑1 have and will meintsm Workers compcmtlon Insurance.M rtquimd by Secdon
3Lg1 of me labor Code,for me pmformance,of the work for which this Permit is issued.
My Workers Cor�onaenTsavtio�n lnsu�.earrier and Policy nu rare:
Carrier: ( // ✓" c YLI`r9 Policy No. VAJI 0Gv'
/ CERTIFICATE OF EXEMPTION FROM WORKERS' /lIG
COMPENSATION INSURANCE IP'
(Thlasection need not becompleeJ if the permit is forone hundred dollar($INN
,it less.)
1 certify thn in me performance of me work for which We Permit is Issued,I shall not
employ any Porion in any manner an pe to become subject to the Worker'ComPensadon
Laws of Calimmim.Data -
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you Mould
become subject to the Worker's Compensation provisions of the labor Coca,you must
,JOfonhwi ih comply with such provisions or this permit shall he deemed revoked.
E�E • CONSTRUCTION LENDING AGENCY -
4 I hereby affirm pen mere iso constmction lending agency for the performance of
> the work for which this Permit is Wood(See.304/,Civ.C.)
D.1 Lender's Name
az Under'sAddress
U Q I cenlfy that 1 have read this application and sum that the oWvx information is
U,f-•' correct.I agree to comply with all city and county ordinances and state laws relating to
O V Wilding construction,and hereby anchorite representatives of this city to enter upon me
[i7 above-mentioned properly for inspection purposes.
V) (We)agree to savusindemnify and keep hay in an the City mCupenstsid City /
ti r/) tomudca,judg u.c uandeaPcnasw 'hmay in any way same against said City
Acnnscyucn q thy�ySming of I(is ' i
A p U DE g AND ICL COMPLY WITH ALL - DINT Issued by: Date
SOU G1 f///_
/ -03 Re-roofs
Si wrc of Applicant/Comranm Data
HAZARDO IALSDISCLOSURE Type of Roof
W111 meappliantorlout Win'octuPantstom ar handle hevudous material
pe defined by the Cupertino Mu ipal Cock.&.Nmr 9.13,and the Hcalch and Safety
Code, ycs ON.n35533(a)?
1::] All roofs shall be inspected prior to any roofing material being installed.
❑ti
'a
Will the applicant or rmurc riding occupant tau cyuipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1 honrdnus air conlemineu diefincJ by the Bay Area Air Quality Management all new materials for inspection. -
uia?
❑tics ❑No
Iheve mad the aWid, under Cheperfi95oftheCalifor-
Hcalthd:Ssrety 3n.IundLMI ifthe Wilding
nm c ndy ailitY m nnWy Ile pins of dm
itm, wh' cmfie oflkcu 1 Signature of Applicant Date
rive avant Dale All roof coverings to be Class "B"or better
L