06090053 CITY OF CUPERTINO
Bumnwc DIVISION
T"C
G� 1NT it X1NktU
IiMA Ii '
BUILDING ADDRESS: GENMOR PLUMBING PERMITIT No.06090053
1022 PENNINGTON LA
OWNER'S NAME: PERMIT ISSUE DAM
HAEHNEL ROBERT B AND BARBAIA J3560 HAIG
NE: SANITARY NO. CONTROL NO.
(408) 855-8348
7ARCE,H]TECTAENCINEER: BUILDING PERMIT INFO
BO EO PLUMB MOjoLICENSED CONTRACIOWS DECLARATIONIOb Description
wI hetebY afI)m Nal 1 am licensed under pmvism ns of Chapter 9(rommenring;tScxdms70r(b fDiv lm3.1 ase Buaneuaad Pro(mead Cotic, dmYlicenseklto=andof COPPER REPIPE FROM SERVICE TO THE HOUSE NO VALV
� License ess 1.1.11
L Da¢ Contractor `I(��
ut,5� ARCHI II DMtLA.A N
i < I cosmonaut my plans shall he used u public records
nyU
:tet; Limnacd Prefcsooml
5 OWNER-BUILDER DECLARATION
)c c 1 boxes.
aReet Nm I am exempt from the Conlnnofs a Any c Law far tits
;cc o following sores a (Sento Bnstru Business and w,dem us Calc:Any city or county
)m� which requirus a permit 10 construct,alma impmw,dcmolkh,or repair any structure $4000
'.zeeprior w its issuance.also requires and applicant for such permit to file a shared satement
that he k limmed pOnuanu0 the pmviskam or us.Contractor's Liceasa I..(Chapta9 Sq. Ft. Floor Area Valuation
IreF (commencing with Section 7000)of Division 7 of the Business and Prafemions Code)or
$ that he is exempt therefrom and the bask for the alleged cmmpdm.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of er Occupancy Type
not mom Nan Ow hundred dollars(5500).
❑1,as owner of the property,or my empioyeas with wages as their able compensation,
will do the work and feesmmure Is oat intended or offered rarsak(Sm.7014.Busmen Required Inspections
and Protrusions Code:The Contractors License Law does not apply to an Owner of q P
property who bui Ida cr im prows thereon.and who utas such work himself or through his
own employes.provided that such improwrtmnla an oat intended araffered forsale If.
hbwewr,Ne Wilding or improwment is sold within as year of compledon.Ne owner.
Wilder wiB haw the burden of proving Nat he did Out Wild Or impmw for purpose of
sale.).
❑1,as owner of tk property am aaeluuwly eonuaeting with IlanxA mnuaeton to
consumer the prejea(Sea 7044.Business and Professions Code:)The COAtraetnrs U-
ntue law don not apply to an owner of property who WIWt a improves da mon,and,
who contracts for such prejeces with a contMor(s)licensed Perot to ate Contractor's
License law.
❑Imnesempsunder See .B&PCfa Ntsmatan
Owner Data
40 WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aa:of the fallowing dalarWoas: '
I ham and Mil mainuin•CaNOeam of Consent m seIf-msum fa WootersCompen-
sation,as provided for by Section 3700 of dte labor Code.fa Ne performance of use
work for which Nis permit lea issad.
❑1 ban and will maintain Worker's Compensation Ima rsoce,as mquimd by Section
37W of the labor Coda for the performance of dte wont for which this permit is bused
My Workers Compensation Insurance crserr ad okay her art:
Carder"keMC1T/CCf F YhEMPTIONFRO:'
t CERfIFlC COMPENSATION
NFROM WORKERS'
COMPENSATION INSURANCE '
Critics sexuan need not N completed if the permit Is forone hundred authors($1 00)
or less.)
I certify Nal in the performance of dm work for which this permit Is Issued.I shall not
employ any person In any meancrso as at became subject to the WOrken'Compensadm
Laws of Califar ia.Due
Applicant
NOTICE TO APPLICANT:If,after making this Ccm man of Exemption,you should
became subject to the Worker's Compenestion previsions of ft Labor Cada you mat
,Jfowith comply wife such pmas W to,
mem.
Or this permit shall deemed kcs.
zDM
� CONSTRUCTION LENDING AGENCY
[r 1 hereby aRm Nat then k a atuvucOm leading agency for doe perfurmence of
r1, > the work for which this permit is issued(Sec.3091,Civ.C.) -
W Q Lenders Name
z L ortim s Address
L)O 1 certify that 1 have road tus application once state dot the abaw infomadon I-
LL (~ comet.I agree no comply with all city and county on inancus and ser¢laws calming Or
pU Wilding conswetion,and hereby authome repruscntmiws of Nis city t0 enter upon the
r W abovomenudiproned pmarty(and expenses
purposes
f+gy (We)agree to saw.indemnify and keep hamlets the City of Cupenino against
rq inconsesjudgmenthe granindethispewhich may in any way accrue aguasuuO City
U z A APPLICANT
of UNDERSTANDS
S AND
Date
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
;SignourecdApplictur Ontnnor Dam
XA ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant a futtue Wilding asupsoluom a handle hanrdaus material
ned by the Cupertino Municipal Code,Chapter 9.13,and No Health and Safety
Section 255374)? All roofs shall be inspected prior to any roofing material being installed.
Yea �NuWill the applicant or future building accupant use equipment ordevices whichIf a roof is installed without first obtaining an inspection,I agree to remove
mardms air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
ct?
❑Yes micro
I hew read the hwrdous materials requirements under Chapter 6.95 or the Califbo-
nia Health k SuetyCode,Secdcas 35.305,25533 and 75534.1 understand fent time building
docs not cumntly hew a hou nt,that It is my responsibility m notify the acupant of Nc
requirements which most bre met poor to i3atuaa Of A Centrum ar Occupancy. Signature of Applicant Date
k"A les( C) 9:,3a=4(. All roof coverings to be Class"B"or better
Owner of authorized agent Dam