02030209 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1107 KENTWOOD AV CUPERTINO PLUMBING 02030209
OWNER'S NAME: APPLICATION SUB DATE
BARBARA MORGAN 10297 S DE ANZA BLV 03/27/2002
PHONE: (408) 253-0618 SANITARY NO. CONTROL NO.
G ARCHITECT(ENGINEER: - BUILDING PERMIT INFO
K BLDG ELECT PLUMB MECH
s.Z e, r_J
oN 3 LICENSED CONTRACTOR'S DECLARATION Job Description
i i-qq 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing P
m.l_ with Section 7")of Division 3 ofthe Business and Professions Code,said my license COPPER REPIPE
is in lull Tone ane eB«t.
i y K 6 License Class Lic.
'�n 6 Dae Q 62 Convenor I -
gu.ti ARCHITECT'S DECLARA ON
g I understand my plans shall be used as public records
i r
3 i 0 o Licensed Profeasionvl
ca OWNER-BUILDER usDECLARATION i I hereby affirm that 1 am exempt from(he the Comontructor'a License Law forth,'
y
? followinguires a(Section]construct,
Businessand improve,
demolish,
emob Co le:Any city or rnunry
O
which ts Pamir t c .t t Iter.Improve demo) t or repay any structure $5000
-prior u nee,also requires theapplicant for parento file asigned statement.
Ihi he S heemed pdrsuue t Np Amyx bas of the Conlmcmrs Ural¢law(Chapter 9
(commenangw Nset ]000) fDnialon3of the Ru;loess end Profemlons Code) t �i�.�? �,y .U[T3 r,'O,®a +• `4 Valuation
or that he If exempt thesefmm and the basis for the alldged nempao l Any violation t �" l�. •`1 I i t}_
-or Section 7031:5 by any applicant fore permit subjects the applicant to a civil penalty 7� ,y
of not mon than five hmmnd dollars 15500) 106�PNiL� #n & WATER ""''" '" Occupancy Type
01.es owner of Ne pmpcny..1 my employm with wages as their node compensation, _
will do the'work,,and the""income'is nm"intended'a,offered for sale'(Sec.704,[" - -
'Busincss ted Professions Code:The Conncmr's License Law does not apply to an 301 - ROUGH P$hiI41BW%s0eetions-..at of of property Who builds or improves Narcan,end who does tech work himself
or Nrou h his own cha to as.provided that such improwme is art not intended or 302 - TUB & OR SHOWER.
.__ _ P-.y- ._ _..._....-.-..._..__._...._.... .._._._...._,_____.._.__.._.._..1._. _.-_-
6 P Yend of ._______..____.___
,n
offered or sale.If,however.Ihe buildin or im-ruvementiiFold wdAin�un` 502 - FINAL PLUMBING ENERGY
'completion,the owner-builder will have the burden of proving that he did not build or
on Prove fm parpoae of,It.). _506 _-_ GAS TEST
. ., ._. '_507_-___
I
co L as owner of the property,am exclusively ssa d Prucsag with licensed contractors m - FINAL' -
_ PLUMBING-
contract the a Iso ]044,Business end Profess ons Code.)The Contraction's
0 — ' PLUMB ING -
License Law project
apply to an owner of property who builds or improves thereon,
'.:: ..and gconwcsuch projects wih.¢conuucmrs.lcemed pummt.to that.
Connecmr'a License Law.. 1. _ i -
❑lam exempt und<r Sec.• "f BdkPCfor Nia mown r. :`[`;i'vi
' Date" ' '
WORKER'S COMPENSATION DECLARATION
']a'' -IherebyafRrmuMapenalty of pc juryoheofibefollowingdeclareticns:
Y�..IN ® L�.®
h
❑ 1 ave tend will rotation.�a Ccnificme of Convent to nl6insurc for We&,,'. v-�
Compcnsmion; as ponAdad-for by Satinn-3]00 a the Labor Gude, far the APR 17 2002 -
performance bf Ne work for which tho permit is issued. ,.
1 have and will'maintao Worker's GSlnpenvut on 1 Science,as ropori by Section p�
TWotheLabor Code:for the Infthe,work'fwhichN's permit is
issued.My Worker's Compensation Insurance camer and Policy
BUII.®ING
number ere:
CerAer.Jrr�T�Ft UN UP Policy No7�/U/J/rKtO.7 fs' •. 'N
YI tr"CERTIFlCATION OF EXEMPTION FROM WORKP.RS Y{ I Ai9 tf .4
COM PENSATIONINSURANCE' '
!'•""''(Thii uiiloa need not be cofbPlacd if the permit is for one hundnd dollen ''r •' \'lI''' ''-" ;r 1. t r!I"i: ;.`t. ;fi'''r:
I certfy that in the performance of thework for whichthsperirut ii issued ! '- "- _ -- � � - t;7LV ` Tc
shall not empleyhry,eirsom in any manner so to'bccome subject to the Workcn
Applicant.,
of Calfmate` "•'"
-CPP�safnn Lawa. . :D
,. ..
__............ __ . _.._ .. ._ .----. _.
NOI'ICETO,APo the Work:IL after Compensation
sCemfcat fth Exemption,you you hold �-
Obecafnel romp to the Workers Compenuuon pa n,alis of the Lind Cove,you most
Yohlt uh c I with such s or sba t sM1all bed d rev coca,
~ ... Y .CONSTRUCTIONLFNDINGAGgENC Y ..�._... - .. ._. _... _. .... _ ._.. I. .... .. ._. ..,_
1 hercb R th t th e s a cenawct on le d o a enc f the rfunhante ;! .(
[ail of shework
for
Lender Name,
hsh this perm t Is issued 'Cia
(Sec.309]'Cry C) '
.._ :,. ..i.:-.-. .•.<:. ,_..., . .. - ._. ..__..__ -_.. ._.._- ,. ._ ...___ .:.-..__._ - - _ _
!sodas Address ._.•... _ _ _..___. .. -__
I anify that I have Dad this application and sun that the above information is -
v=[ coven.1 agree,to complywithallcity anti county,uordiam".hand!state laws mining
on
to Wilding cswction,aM ' o . authorize nepnmatives ofthis'city to enter upon as
the above-mentioned pe for in tion purposes.,
F.L (We)a e't' e d Steil ,'nd kap hsum le sthe C tY-4 C.'Pia eisiaaI
,r V] city u j ten s,ic ted Loses which ma toy ey accme egvnst cid
V
city n quell a ren I g of this p t -
DS W WIL MPLYWITH'ALL"NDN-POINT I'
APP 1 F j u r s 2 a Issued by: ate
Will the lican o future Wilding occupant 0f Tepe OTS
DIEee Applicant AZAR OU TRIALS DISCL SURG Da
Cadapp S pa handle hazardousmetenel Type OLRoof _
¢fined i. the 32(n,n Municipal Cad Chapter 9 12 end the Health end Safety OOf .. _.+._ --:.
e Saton 255J2(ao .
❑Ye11 )
All roofs shall-be inspected poor to any roofing material being installed.
Will the appl ronin f t re Wilding weapons useact ipmeatordevnces w-i If a roof is insfalled'without first obtaining an inspection I-agree taremove
emit h tratd s a r can defined by the Bay A Mr Quad ty Menagcntem
Mahout?, - - all new materials for inspection Applicant understands and will comply with
l ❑Yn,s.l ,-,. 1 . - _N try '.. ' all non-pointsource regula ions -
!,(1 havelread the hazWoas materials ngmrementiuunder Chaptte '6.95rof the
Caliromn Health,gs Safely Code;Sections 25505;25533 and 25534,1 undersand Net
iftheb ilding, Sf no uertoiln haven tenant that lis mYrcsponslbduy to notify the
Inecu IPf In'requi mel Ash muss be metp or to issuance of a Certificate of
Signature of A plicant Date
otmore 3 a Da¢. p All roof coverings to be Class "B"or better
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_ '...� .. .OFFICE-. .
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