01120001 CITY BUILDING ON
UPERTNO
PERMIT CONTRACTOR INFORMATION:
B1181G�ff"Wi LLOWBROOK WY PERMrrgNO y 01120001
°°f" WjNtbNOFRIO Al 03j2001
PHONE: SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: BUILDING PERMIT INTO
N5mF�j BLDG L- A PLUMB MECH
L I 1—U LU7 J
g N KK_ LICENSED CONTRACTOR'S DECLARATION Job Description
DZ Ihereby affirmthat Iamlicensed under provisiomofChapmr9(commencing REPIPE TO COPPER IN LINE.
aYi� with Sation]O�t10k),of Division lof the Business an Professions Code.and my license _
is in full lor<eG t. / //Ykn a
E rc z< I.I[rnX CIasF LICA li kY!_/L1111 /fes
O i U Da¢ Conuoctor
aret A HITECT'S DECLAR I AUGz a 1 understand my plans shall be tared as public rtcn M
i-O O Licensed Professional S 2pp2
OWNER-BUILDER DECLARATION
I hereby aRnn tat 1 ore exempt from the Commnor'a License Law f the '9 V`/'1eD,jV
t? m1mving remon(Section 7031.5.Business and Professions Cade:Any city or county 2 8 Q Q
4 F O which rtquites a parmit m conswet,tier,improve,demolish,or repair any stmewrc
-prion-its instance.also requirem
s the applicant for such patit In rile a signed statement
Nobe I�nsedpbis Itotheproisionsofthe CommmorsLicense Law(Chapter 9 36SA312a�Kfta r Valuation
(c mttane g will!Sauo ]1100)of Divisionlof the eutness end Professions Code) i 1 y 1, sit 1�
a Net hats 31.5 b wyaWli=t the hays fnr the alleged okernpuon.'Any viM.Ity 7
of net mo 7011.5 b e hundred doll frs a permit subjau the applirnm m a civil penalty-
.nfnot more than fisc nnnNee dollars(g500). 202Ap'N 42FLOOR PLVMBING Occupancy Type
°1,as owner of the pmpeny,or my employees with wages as Their sole compensation., 301 - ROUGH PLUMBING
-will dd'the ad Pro ssionsand e strurude T e C.a, intended or offered for sale(see.Tau, 502 — FINAL PIgj4a'jBIrAspBA7r0�Y '
Business end Professions Code:The Com or law does not apply men I '
-wren of propmy Who wady er imprnve,thereon,and who Jona wen wank him.alf 507 — FINAL PLUMBING
or through his own employees,provided Nat such improvements art not mended or
offered for sale.If,however the building or Impressment is sold within one year af' _.. .._ .. ._.. ..... .. .._.. ..... __ _. . .. . .._ 1
completion.The owner-wilder will have the burden of proving that he did not build or,
improve for pmyose of sale.).
... owner of
.e ....tract_ with
licensed
_ . .._. ...,_............ .... _. _. .. _.._. __ - __ -
O.I:m ownerMi a pnec.'l am Businv,ultivess
and Professions
Ccdc:)The Contractor
onti ors to
License the does
no(Sec Ro a Business and Rly who
Cade:)The improves
bamor's
License Law does nm apply. an owner of incipiently who wilds or impmva thto The j
'
Cumeaco.conoa. for such.Pmjau with e.commnor(s).licenud pursuanLm the. ,.._.acct„.._._ .___._ _. ._. _._ ..___..__. ._.._. ____..._ acct.._tract.._
_ Co1 an I.rr Liccnde law.
- °lam exempt under Sar. .B&PCfar this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby apron under peclry of perjury one of the following dalantions:
° 1 hove end will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 17W of The Iawr Code, for The
Performance of the work for which this permit is issued.
°1 have and will maintain Worker's Compensation Insurance,as required by Section
1700 of the Labor Code,for the perf-sera of Ik work for which this permit is
'issued My mri Compenmuon lmmrancecamereboPl' ba ve.
.. ._. . . -a... .. .. .-. a _.
P�t 'Pal cy No.: Ue ...... ..
tamer
t ('1 fICERTIFlCATION OF EXEMPTION FROM WORK RS'
E
COMPNSATION INSURANCE
�. _
''tl (Thai uctidn need not he completed if the permit is for one hundred dollars
($1 M)or less.) .
1 ccmf Nat m the rfmmu Ia of the work for which(Ars mo is
Cm issued 1 '
-- Y - - T- _ -
a aonot employ any person m any mann X m manner as become sub)at to the
Compensation Laws of California.
ia.Da
Applicant
If,
you
,NOTICE TOAPo the Workrs Compensati thisCertificateof Exemption ,yumuld. •I •' ' .�'
the Worker's Compensation previsions of The Labor Code;you must
comply.` with such provisions or Nis permit Nall w deemed revoked.
t '
� Mbefome sub'ea iota
Q z lonhwrth
(•' � _ CONSTRUCTION LENDING AGENCY
1 h ny Iran that th rc s issued(Sen nd ng agency f r the perfurmance
1.
Wof the work for halt his perms is issued(Sec 1097 Crv:C)
y.A .UdersName .acct .." - c. . ... � . ....t ..: .. ..... .. .. .. . _
u. Z Lendn't Address,
V I cenify that I have read This upplication and state that be above information is
Q [r
To t.l agree to comply with ell city land county ordinances and mute laws relating
t„) to wilding constr6cion:and hereby amhoinanijrcsentatives of this city,.emerupon
the above-mc a property for,inspection purposes.
�Lr Q,1 (We) me save,Indemnify and keep harad as tie City of Cupertino against
W liabilities,j dgmrn ,costa and expenses may in any way,aarve against said
V City in co equen of the gramin rmic” '
APPLIC TO ERSTANTI. LL COMPLY WITH ALL NON Issued by: Date
on,
SOURCI [ CATIONS. " ' 1 OI y
'Sen uWilf thea I L[or HAZARDOUS
MATERIALS
RIALS DISC Date Re-roofs
SCLOSURE '
"� gactapar or ha, lantard�rnwaial Type of Roof...
as defined by.the Curbstone Municipal Code,Chapter 9.12.and Ne Health and Safety
Cm Sen n735721 )n ., t r
°Y`a All roofs,shall.be Inspected prior to any roofing.material being installed.. ._
Will the applicant or future-bum g occupant use cqu pment or device.which If a roof is insfalled without first obtainingan ins ecnon;1'a ree to.remove
em t h raid- a m r co tame B defined by the Bay Area A iManagement p g
DI tnetn all new materials for inspection. Applicant understands and will comply with
°Y" T1113 No all non-point source regulations..'
Dgad.cs
a hliadoue;pimerad,requi¢mentsdLatin,Chapter6.95 of Ne
Califa fay Code;Sctdons 505,8511 and 25534.1 understand tial
I t afcurten0yhe nt that it is my mponaibiliD tp notify Theuccummams xhi vin be ren prior m issuer¢o!a Certificate of
Occua . . . ...
x dr �w Signature of Applicant Date_
'•�. own ramboriaedag-a' .Date All roof coverings to be Class "B"or better .'
q_ .,I•..,, ., C..... . :: r .. .:. ...._.. OFFICE . ...