01050200 CITY YlOFNCUI6RTNNo PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. -
19387 SAKURA WY CUPERTINO PLUMBING 01050200
OW'NER'S NANIE: APPLICATION SUB DATE
GI_YSSON GEORGE E 4 1.0297 S DE ANZA BLI, 05/30/2001
PHONE: SANITARY NO. CON"IROLNO.
(4013) 283-0618
Ore ARCHITIiCTIENGINEER BUILDING 1'IiRMI'r INFO
wp BLDG ELECT PLUMB MECH
Qib CI CI IJ I=1
=N
G LICENSEDtCONTRAGnOr owituLe,.1 Chapter
t Job Description
Q 5 g a I herby 0irm that 1 mm of died under provisions of Chapter v armory
Iie img p wke ith Section nr D'avidnm3nnhn Badness and rrofes,iom ends,onto ttty acerae
rcxt' isinfull Poenim effoa
zea Licemaela5 _� Lie WATER SERVICE
e'O i at
Dole
Gnnll'umor-' t
3 u v ir1'IiCT'S DECLARATI( -
C
food any plums shrill he rani v.poblll lecmds
pO Licensed It bessional
ca OWNER-BUILDER DECLARAI'[(IN
Hsi=m I hereby aRmt that I on exempt from the Contractor'.License Lw for the
CG follolvingrea,cri scolon 703I511 ml Pill ..i , C 1 Any '1)to county
$FC
which 4 incrantr cot t hp I Illi repynt cma
1`Ii C pr, t 1 al lir pplwart t hlw tt 11 ,b J.ltment
that he licensed,pursuant it)theprovisions
of ComrrascclLicenseLaw(Chapter 9 Sy. FL Floor Area Valuation
(voinnownein,wlh Section 9100)nl Dvvikimr 3 of the Bud nes,and Profksmom Code)
or that he is exempt Jarel rnn,and lire hams lot the al le,ed kxkntptio I Any violalon
of Section 7031 S by any applicant for apvrmhsubjects the applicant to a civil penally ApN NbOccupancy Type
orn,ann unm
I,, Irto five It died rotor, Number s(S50(b, P Y yP
❑I,n of the property.a my employee with wage. ;thcirw4c,urprosI him.
will do owner
and the>Irvclum is not intended or offered for.ale(sin-7034. 3751 5
Bminess and Professions Code:The Contractor's Liecrwc Law does not apply to an Required Inspections
rot proprny Who hadds or improves m
rovunun,and who linen such work himsdl'
er through his own employees.pn,vmed mat ouch improvements are nm intended to ` 103 — UFER
offered for sale.11 however.the loodding or hoprouricur is sold armin one y ter of
complef [lie h IJ will the burden Ip Proving lid rhildor 1,06 — SEWER & WATER
improvefor P 9^: I 1
p perryexclusivelye trctnB ithl I t ctnm 507 — FINAL PLUMBING
❑1, of the
construct he P'9u IS 9(94 ❑ I 1 r fu
n
)Th C t ut
License law tines notaply wan ownerom irr whobuilds ori nprmc.thereon.
and who clot such prglcros with v contractions)gcapursuant m the
Connector',Lo,re law.
❑I am xcamorder
Sec. .B k P C for'his real
Owner Dole O/
WOR K ItR'S COM 11ENSA'f10N DECLARATION
I hereby aftinm under penalty of perjury one of the following declarations:
(100 ❑ 1 have and will maintain a CeniOcate of Consent to elf-insure for Worker's
Can,.nsuGun, m pmvidcd for by Section 391X1 of the Labor Cuda for the
performance of the work for which this permit is issued.
❑1 have and will mwintain worker:Con..c...fint Insurmme,as mrim d by Section
3]10 of thehor .lixle,for the perfonnantt of the work for which this permit is
nonan rMyl a r adnn ln.arm,c corrin+suin'uh,,number are
J
C l'II:ICA'rX OF LIEMP11 iONTROM WORKERS' -
COMPCNSATIONINSURANCE.
mit,section need not he completed if the permit is for one hundred dollars
(R Print or less.)
I cenify mat in the oil move of IM1e work for which this permit in issued,1
,hall not employ any person in any internal so as on become subject to dm Workers
Ctmnpenxntion laws of California.Date
N(YfNUIICE
E
CETif APPIAe Wros If,oberstakingthiswl,lu kmf of he LalwortCodyou should
hechwithc mpv,the Workao'uwombi sman pmvisi dualI he
Calk,you must
Q O litnhwim comply with.amh provisions or this pornlit ehnllh JccmeJ loaded.
Fz CONSTRUCTION LENDING AGENCY
C1 hereby aRmt that then is a construction lending agency for the performance _
or the work for which this fiction is i,ard(So, 3007,Civ.C.)
0. C I<ndcr's Num.
D Z Lender',Actions,
U Q I cenify thin l have mad this application and state that the alive information is
ie. (�. c.runt.I agnn to'o nilly will,1,11 cry:rad.aunty ordlnjmcn.and"air taw1 rci ning
C) (� ,I building construction,and hereby aulloove represcntahves of this city to enter upon
llie nhuv.-m cntioncd,orwri,I..inspection mrpswwn.
F C6 (we)agree w
save.indemnify and keep hairless the City d cmarna figura
(n llilbllilics fragments,costs and exi,rmcn which may to any wily accrue against said
V z Cit recyue cc nt the gnnuing ol'mis perltt 1.
Sail. 11'fl +EN� ANDS AND WILLCOMPLY WITHALI.NON-POINT Issued by: Date V "• �•��
Signmuraof Amfica 'nmmctur Doc Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buldingtncupam sten or handle hwardous mumrial Type of Roof
us d.lined by the Cnlmninn Municipal Cole.Chaptar 1).12.and the Ilcalth and Sul cry
Code. cu 25532(x)".
❑Yeifs, u
y]\ All roofs shall be inspected prior to any rooting material being installed.
Wdlmeapplicant tor floor,hldmin,,wanpanta..etImplarmordesire,which If a roof is installed without first obtaining an inspection, I agree to remove
mint on,urdom,air coalal as del'med by In oBay Area Air Qu,.lity Mnuaglunerl
31.hrrrt '"° all new materials for inspection. Applicant understands and will comply with
O ye, all non-point source regulations.
I have maid the hamrlous marmiuk redui rcments ander Chapter 6.95 mthe
s California Health k Safety Code,Somiun.25505.25533 and 2553.1.1 end ernhmd mat
it the 'ng does not cu ntly have a tenent.that it is my nslnm.ihility to manly the
atm of d nquir nx ich mute In,met unit e,issuance of a Cerifa.aw of
rx a m ��� i Signature of Applicant Date
Owner t•randtnritedage IO .All roof coverings to be Class `•B"or better
OFFICE