04090158 777777,77
CITY OF CUPERTINO ids '�7 aE* 3ssF
BUILDING DIVISION PERMIT 9 W �w''a• a
BUILDING ADDREss: MELLO PIPELINES INC PERMIT rvo04090158
ER'S NAME: „ PERMIT ISSUE DATE
MOX
PHONE:
SANITARY N ROL 10.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG" ELECT PLUMB MECH
0 o LICENSED CONTRACTOR'S DECLARATION
I harohy affirm that Iran liamu d umkr provisions of Chapter 9(commencing Job DescripFINALED
i with Section]agB of Division Softhe Business and Premiums,Code,and my license is
n=z rn in full toand offset.
5 z License Class Lm. 3 SANITERY SEWER LATERIALS
q Dam Gamre LOT 1, 2 , 3 NOV 2� 2004
ARCHITECTS DECLARATION
ARATION
y 1 um mnstand my plans shall he used as public reco is
Dy
j Q Licensed Professional B U L L I N G
3
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am attempt from be Connector's License Law for the
OD following mason.(Section 7031.5,Business and Professions,Cade:Any city or county
K$� which requires a permit m cnnsuuct alter,impose,demolish,or repair any structure
u�r^ prior to its issuance.also requires he applicant for such Permit to rile a signed statement
C�< that he is licensed maimaouo the provisious of the Chummier's License Law(Chapter 9 Sq.Ft.Floor Area Valtia�l900
,FC (commencing with Section 7")of Division 3 of the Business and Profession&Casm)or
y $ that be u exempt t here(mm and Ne basis for the alleged cxempit..Any violation of
Stenon 7031.5 by any applicant far a permit subjects me applicant in a civil Ponalty of APN Number Occupancy Type
not mom ream five hundred doll.(SSW).
❑I,as owner of the property,or my employees with wages a Nair sole compensation. 32625016. 00
willdothework.andtheswctumisnatimmndtdorofferedfemale(Sa.7D .Burituss
and Proossiom Code:The Coneaamrs License law does not apply to an owner of - Required Inspections
property who builds or improves income.and whir does such work himself or through his
own employee,provided thetauch Improvemenlaare railroaded or offered for sale.Ir,
however.the building or improvement is sold within one year of completion,the owner.
builder will have me butch of proving mal be did not Wild or improve for purpose of
sale.).
0 1.as owner of the property,w exclusively contracting with licensed amanuensis to
answct me project(Sec.7044.Business and Professions Code:)The Contackurs Li.
arae law does not apply to an owner of property who Wilds or improves themun.and,
who contracts for uch projects with a connacmr(a)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. ,B&PCT/ry Nie mason
ct g Dam�—
W R x/l IPF�1� ON P.
I b y aR under pen ty off-ptrjuryone of me following declarations: -
1 have and will maintain aCenifieemof consent to self-0nsure for Work u'aCompcn-
sation,m provided for by Section 37011 of the labor Code,for the perfmmuma of the
work for which mis permit is ismad.
I have and will maintain Workers Compensation becomes,as required by Section
3700 of he Labor Code.for the parfarmmce of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Polley number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ssetten need not be completed if the parent,is two=hundred dollars($)W)
or less.)
I certify that in the performance of me work for which ibis permit is laved.I shall not
employ any person in any manner so as to becomo subject to the Worker:Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of me Labor Code,you must
.JO forthwith comply with such provisions or this permitmall W dcemeA revoked.
„'�„H CONSTRUCTION LENDING AGENCY
I hereby affirm that dome is*construction lending agency for me performance of
me work for which thatmit peris issued(Sec.NOT.Civ.C.)
W� Q Lender's Name
Z)z Lender.Address
U 0 I certify that 1 have read this application and suit that the above information is
f~' correct I agree to comply with all city and county ordinances and sus¢laws relating to
DU building convection,and hereby embodies representatives ofthis city to enter upon the
W shove-mendurnd property for inspection purposes.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
fz�q itabilitmyjudgments,costa and expenses which may in any way acerae ageintmid City
in
of to granting of
V^
APPLICANTUNDERSTANDSArs Permit.ND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCELATI S. 4Q
/ Jit Re-roofs
Still of ApplicaroConuacmr x �j.
HAZARDOUS M RII dISC(. R L.teP. Type of Roof
Will tW applicant or future building occupant store or handle harmonious material
definmd by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety -
e.Section 2ss32(a)7 Yes All roofs shall be inspected prior to any roofing material being installed.
�Bu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to,remove
emit W7.iudous air communicants as defined by tho Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes f3rvu
1 have mad dm hanniouemamrials requirements under Chepur6.95 cf dot Califor-
eiaH.Im&Safety Cnde,Sections 25505,25533 and 25534.1 undorm nd muff dm Wilding
dos not currently have a tenant Net it is my hummuibility m notify the occupant of the
mquimm tawhichmu melpriormiss Ince of.CertiricamofOccupancy. Signature of Applicant Date
nar tar uthorWzd agent arc
All roof coverings to be Class"B"or better