01100164 CITY
BUILDIN >DNlv
rEeOo
GPERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: I PERMIT NO.
21600 RAINBOW DR BUDGET PLUMBING 01100164
OWNER'S NAME: APPLIC9TI3ON SytB DATE
LAU LOUIS Y AND PHYLLIS ANN 28695 ROANOKE ST 10/ 1/ 2001
I PHONE: (510) 264-1113 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
m Q BLDG ELECT PLUMB MECH
�b
LICENSED CONTRACTOR'S DECLARATION
S i 1 hereby a17 m Nat 1 am licensed antler pmvi,io,of Chapter 9(eommerem, Job Description
'41-u� x'ith Section 7")of Division 3 of the Business and Professions Code.and my license REPLACE WATER HEATER
r Y 2 M is in full force and effect.
O y
U License Chon Lc.a
Dec Contractor
ILL O<r_ ARCHITECT'S DECLARATION
I understood my plans-shall be used as publm
ic cnNs
I a O O Licensed Professional
OWNER-BUILDER DECLARATION
u u 1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 703 1.5,Business and Professions Code:Any city or county $72S _
ce a which requires v mit perto consumer,alter,improv,demolish,or repair any unucome
i3m _pow
r.- '�,. Valuations
_
the rymencing%ith Siectiol to Nuc ofDi ons vision Ne Ce Businis License chaporr9 Cod) 3 Rg., �;p-.�
(rammfit 19 i wish Sectionr;tViol Or basis
o the
itiif 56ma Professions Come) a_t. 5
or Nn tie is exempt Nertfmm and Nc basis far the acts ths,descant t.a ny violnion
-ofSection a than v very applicant for a permit subjects the applicant m a civil pmalry-
mrnnptnnretWnrvehundred dollars lasnu), 502°apNI'PI2RbATL PLUMB IN ENERGI'OccupancyType
❑1,as owner of the Mist or my employes with wages as their sok compensation. 506 GAS TEST
-.ill do'the'ard'Prk.somm,and Coder:
Cnot eum'ii N-riri;e La does ron apply
to 1a,- 507 - FINAL PIIZ fiMspectibnsl".;'- L,xr..
rowners'pre,' bons Code: ire Contractor's License Law s such
nm apply tow .
ow
«rofhis
embuildsmimproveot such,and who does ouch workhimself. t
or through h's n ply ...... J that such mpmyem m of t intended or
BRc J'f} Ip If.M1 w th tie Id n er«m is sold N' one-it of
g of Improv yc
con Nbue owner- Idcr will have On Wrden of proving Nm he did not Wild or `
improveprove for purpose wf sola),
Y OLasownerpmjec p(Sec.7 am Business
trofeingwi CodcnsThe Contractor's
mnewa the ors a(Sec. to 4.a ousineo and Professions Code:)The vee cinam.
and.who conuacta for.such acts.with m mrm3 1 ❑ t.to O
c 1 m m"Li under a..y Wo3- I y ,9&P CPf this to Ne ,i
License Law docs nota I to an owner of n h Wild. tb ` U
It
Contmcexempt undo law q 6
_ ._ - p�I�Y, INI s,, t
Owner Uim
WORKER'S COMPENSATION DECLARATION �V�LPY�f�t6T
-1 hereby affirm under penalty•of Perjury of the fallowing declinations:' V
❑ 1 have and will imimtaih a Cenificme of Cruise
to self-insure for Worker's
•tt` Compensation;as provided for by Section 3700 ofheWbar Code, for the
performance cf the work for which this permit is issued. .,
'l Y 0I have vnd will mainuin Workers ComAzeam n lnsumnce._as required by Srainin
37W ofahe'Labor Coda foo the performancew
,of the wk'for which this permit is
_issued-.My WOLka, Compenssuov lnsun wrre tiJ Pul cy. u here:' _ - - -
CumerrPoI¢YN
';1.CERTIFICATION OF EXEMPTION FROM WORKERS s„r + ) "^t�,�T,,1,p )
"� '''` iTnis section meed now tri roe Incd if uM1e 1 rx for one hundred dollen r' :'` '' ' i„t.,.D r dl..` 1' '
($IW)or less)
... .__.�,...-...._.._.._.__..y..___. ..-�.. a -.._....._.,..... . _-...
hall I certifylOm in the perf n of the k f which this ct Workers'l
shall not employ wy:fewer n any manner so as to become kub)m to Ne Workers
Ccmporisarioti Laws of California.Dna
.Applicant " . . :: ,,, ..-..._ ... _._. .._-...._.. _..._ -_ .___. ..... .. . .... .. _ _ ... . .__... .. _
'NOTICE TO APPLICANT If,after making Ns Cambrian of Exemption you should ” - -
z becomine ewb3 et in the Wok ' Co pc ..im.provisions of uh Labor Code,you must
00 fonh th ply uhh such p or his Pe t hall h deemed revoked,
. _--__ - . _ ._ ._.
._ -. . _ -.. _... __ . -._ . _ ____.-.-.. _... .._.._ _
F'. y! ..yr . "0i dCONSTRUCTION LENDING AGENCY ''''"
r I hrrclbyITm
e nhtO 'v rimsintiction rndung.&Imill for the perfrmantt
.'i the work fp hich thispermiti d15_309]`' C) -t.,
f.ender'rName"'-"''.•a"•'_•• -•. a I_ —. __ __.. _._ _ -._._.. .. _. . ........ _ ... ..... __ ... .._ ... ... _ _.
jud,r'xAJdress'7+ _
V 01 c ntfy Nn 1 have rtad N s appliat on and st t thou N bo f rmauon•s
correct 1 g t omply th II vuy and crourty,mbomors and.smm laws alaung - --- ------- - -
0'.f� to Wilding construcii6Wandh by amhmifii representatives of this city u enter upon I
gym:W the boa to edproperty f pati purposes.
- ” ���,✓,� .. 0� t sL� _.
{s g (Wrjigrceioeave, demnify and keep harudes,i City of Cupertino egvrnst
L:. W liabilities,judgments,costs and expenses which may any way accrue against said
.V,z Coy nona4guchen ofN grami.,of Nis pc t _
F
p('LI,E NS.CAN'T UNDER ANDS AND WELL COMPL-]'WrTH XLL hONyP01hT" Y
" - Issued b Date
SOURCREGULATIO
Signatureof ApplicmVCmmactor /' ";Y"I 'i ^:'"Dater Re-roofs - '-
HAZARDOUS MATERIA,:"LS DISCLOSURE t
az' W II Ne a'Orwt w firmm bu b' u t tore or hwdle havrdous fun tial
pp re Pan Type of.Roof.
eco d by the Cupertino Municipal Code Chapter 9.12.e d On Health and Sakry
e.
Crv3e OY 25532(.)? tNoj��,,, �ii.':J r ': A1Lroofsshall.be.inspectedyprior_[o.any.roofing ma[erial.being`ins[alled.�. ._.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,-Iagree to remove
emitbracict? dous'air contaminants as eeonedD NeBe Are.Air Qmdlty Management
Distemit he r
all new materials for mspec[ion., Applicant,understands-and will,comply with
oYt, - ;,I, oN•,'-„ ,_.,; all non-point source regulations:
" - - ,XPi 4l.
Iia Health
e r atl,Sa barardo sS mmenal reg 3 a and Chapu erstan f that
ithCale mil building
dos Safety Cody;aver te ant.that
and I undemm�d that -
-if,iM1eMiilNn Boca noicurtcntl haven meront.Nat ii is m'-responsibility - - -- - - - -- _ --- -- - '
g y yto notify the ,
occupant or Ne rcquimments wh ch'musAlbe met poo Ito issuavc f Certificate of
Oce pa ey -
"_ _ Signature of Applicant -- - _ , .. -._ Date _
,.. ;
Owner or amhnaca agent t are All roof coverings to be Class,'B" or better
. . _ -OFFICE