04100173 CITY OF CUPERTINO - ah+a7-� �w�--7777777--=---7--7-7777r7777-'77-77777777777777-7777,,, ?t
BUILDING DIVISION PERMIT CONTRAC'�TOR�INF.ORMATI®N °�. - - _ _
BUILDING ADDRESS: PERMIT NO.
7
CUPERTINO PLUMBING 04100173
OWNER'S NAME: PERMIT Icc11E DATE .
SANITARY C OL NO.
ONE:
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDG EIRLT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION -
_o C I bc¢bY affirm that 1 am licensed under provisions of Chapter 9(commencing _ _ _ .l Sc p O
,n with Section 7")ofDivision Sof Nc Business and Professions Code.and my license,is
imm�roroeantlefr«t. tA1F4ECC10S
REPIPE & WATER HEAT
,t2_ License Class
nt:iDa¢ EC R1 antler NM1 mY 'use u uWic rtt ..... . ... .. . . .. .. - . _ _.
�aG y NOV 2Z
200
a_ars Licensed Pns(
I oc OWNER see ECic CommON 11 p ppp
a 0 1 ¢hy al'fifm Net 1 fico exempt from Ne,Commences License Law for Inc - O
x00 following rmeann.(Smuen 703 1.5.Business and Professions Code:Any city or county II�J" Illi
m which requires a Permit ,,consumer,filler,improve,demolish,of repair any stracmrt
zi prior m is issuance.also require the applicant for such Permit to file a signed statement
< thv he is licerued pursuant to the provisions of the Contractor's License Law(chapter 9 Sq.Ft. Floor Area Valua on
a�0 (commencing with section 7")of Division 3 of the Business and Profusions Code)or .. _
i $
that he d exempt therefrom and the beta for the alleged exemption.Any violation of _
Section 7031.5 by airy applicant for a Permit Ne appacanuo a civil penalty,of 3, I$tQ1�3e�p Occupancy Type
nal mom than five hundred dollar(55007.
❑I,uowmee of the pmpcny,or my employee with wagesM Heir sole compcnutlon,
will do thc work,and the structure is notinanded oroffered forsale(scc.7061.Business
and Perfecomis Com:no Contractor's Limnse law does not apply,to an owner of Required Inspections
mam
ldsorim car
docsamehended at offered
for Whbishowever.
provided Nal such improsemenu tae Out intended ter oeertd for sale.owner..
builder Nebuildingofimprowmcinissoldwithin ane year of improvforn.Neposeof
builder will have the burden of proving Net he did not brill.r improve far purpose of
sale J.
❑1,u owner of the property,am exclusively contracting with licensed contractors b
consumer the pmjecl(Sec.7IW6,Business and profusions Code:)no Contractor's Li- -
cense Law lou not apply to an owner of property who Wilds or improve tamer,and
who containers for such projecs with a conuactor(s)licensed pursuant Ne,Contractor's --
Liana taw.
❑I am eaempl draft,Sec ,B&PC for this mason
Owner Date
737MWORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following declarations:
I have and will maintain a Cenificare of Consent to selGinsua for Worker's Compcn-da.,u provided for by Smile.3700 of Ne labor Code.for 0m perharma�of the
mk far which Nis permit is issued1 have and will maintain Worker's Compensation Inaonnm,as required by Section
of Ne Labor Code,for Ne performance of the work for which Nis permit is issued.
Y Worker's C mpenaaonImemneecarrier and Policy qnimate/,a��re / I ,,rtier.�PolicyNa.:VrN 76,0 La -
ERT �CA F EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE -
(Induction meed not he completed if the permit is for one hundred dollars(51(10)
or least)
1 mr ify Nat in the perfnrmanec of the work for which this permit is issued.I shall nm
employ any person in any manner so ra to income subjen to the Workmi Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccoricate of Exemption,you should -
become subject to the Worker's CoreNnaatiou provisions of the tabor Code.you must
.,O foMwith comply with such provisions or Nis permit anallo deemed.,.ked.
? CONSTRUCTION LENDING AGENCY
I hereby sham that them is a construction lending agency l m to performance of
D: Ne work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name
_z tinder's Address
U O 1 certify Nat I have mad this application and SLAW that Ne move information is
correct,l agree to comply with all city and county ordinances and cute laws relatingm
�U building construction,and herPY'ntorim representatives of this city to enter upon the
ahovc-mentioned property for inspeedba purposes
HG (We).9.totsaw(indemnify and keep humless the City of Cupertino against
4Z) Lim 11,u.jutlgmcnu,a to ende ia:nsu whit meq' any way ammc against said City
in cmnuyucncc Of th4gmnting Nis permit ^7//
APPLICANT N���RSTAN S ANO W L C MPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE
0 Re-roofs
Sign arca pplican Date
HAZARDO S ATERIAIS DIS esu Type of Roof
dl
the applicant of future W ding occup rm stue andle hazWous material
as defined by to Calhoun MuniciPh .Chapter 9.12.and the HC]IN and Safety
code,section 25532
(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applosnt or future Wading occupant arc equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
I
hvafdous air com earnana as defined by the Bay Area Air Quality Management all new materials for inspection.
District'
❑Yes // N
o
thaw ieaJ lk WaaAnus reqs' cocoa underChapmr6.95 of Ne,Cali(nn
ria Hcallb!Safgy Code.Scnio2553 and25534.1undersundthmiflhcWilding
docs not cdrtd try hew a anmy ponsihility m nuuly Nc occupant mf the
mquimme a hie fmuu 'eC 'Ecim.foccupancy. � Signature of Applicant Date
0 9r mnrm / �I Dam All roof coverings to be Class"B"or better