01120052 CITY OF CUPERTINO'
BUILDING DlvISION PERMIT ' ' CONTRACTOR INFORMATION:
nJIJV4�)ORESPHAIR LAP DR 'CUPERTINO PLUMBING pERMITNO. ;, 01120052
Ake07D UAY D" AND GLENDA C TRUS E- 10297"-S "DE—ANZA BL ] �
PHONE: (4 08) 253-0618 SANITARY NO. CONTROL NO.
:]•�z ARCHITECT/ENGINEER: BUILDING PERMIT Uspo
f'u ae BLDG ELECT PLUMB MECH
Q U LJ 1=1 C-3 1-__I
z LICENSED CONTRACTOR'S DECLARATION
Ifinery air.that Iamlicensed under pro.hsinnsofChaplet 9(commencing COPPER REPIPE, J4aAPF ptf4BATER' & WATER SERVI
u with See..7000)of Division 3.1the Businasand Pmfcesiom Code.and my licrox
is in full force and q!f ce.
ij a u LicenseClan. l._� J Lie.p
a LL y Dae— — enntmmm
u o 5 1 a dcrsond my plans shall hi,used as public re
i vla
iac
80 u. Licensed Professional '
' o OA'NER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Low for the ., $5000
o following mason.(Setters 7031.5.Biwines,endons Code Any door county
which q t pe t tconstruct, h improve,
demolish.or repair any strvnurt -
�3= prnnhpe. 'no fleas gneJ so¢mem - - -
0iahe0si' rep noth,in p s fth C t t :LicenseLaw(Cbaphe99A t Valuation(nom ening with Seaton 7000)or Div cion 3 of the Bus nes and Rmfecsions Code)' . ,
or thbi ne is exempt thertfmm and the basis for the alleged exemption.Any violation I -
of Section 703 L5 by nay upplicani for a permit subjects the applicam to o civil penalty _--
ofmoi more man Eve btumpa ammo(5500). PN.N Occupancy Type
.. 01.., be,mfthepropent'o,myeadicycexw;thwageammebsoleeompamadom, . . .'-301 - ROUGH PLUMBI G(_ r =1.
will do the work.and,he structure;s not intended or offered for sale(Sec:](M4,
. Business and Professions Code The Cnmracmrs:Liame Law does not apply to an — ._ .._. .. ... .._..._ ._-...... eC ton$.__._.._..._._._ - ._.... ._.. .. _.._._..
owner or pm,snoy Who Woad,or imprnvek thereon.and who d«s such work himself 507 - FINAL - -or lhmugh his own employe,provided mat such iopowIntmis arc not imported m
'offered for sale.If.however,the Wildingt is sold within ane veer of
or burden
f pro
completion,the owner-Holder will have the Horden of proving that he dies not Huila or
rotate v,in,,purprn °f sale).
01,as°weer of pohep(Sec.lam cusinla I essadProfessi combat.ting withcde:) h Contractor's
oazmtsm -construct the does
no(SIL. to a,Business and Professions Cade:)Theimproves
Co thereon,
License Law docs nm apply man owner with
.I ny who builds v improves thereon,
. ' sand woo wooers for such pmjeas wi,h u unurannr(s)licenses pursuam to,he .... ... ..... .. ._. __. . . _..
Contm Licee lax•.
❑lamexempt under See. � � .B&PCfor this mann .-. .. /1
-- Owner Date /l J
WORKER'S COMPENSATION ON DECLARATION
-�. 1 hereby o irm under penalty of perjury one of the following declarations: O /
° 1 have and will it,; a. .Crod,nm of Content m alf-imam int wnde's C\
Compensation, as provided for by Section 3700 of the Labor Code. for the
poformance of the work for which his permit is issued. .
01have d will mainlain Worker eCompensation Insoorice.as requiredby Section -
37W 1 the Labor'Cont far the rf f Ilic work far whiuh a'.perm i s - . .. -
issued.M}'�y Worker,,Cao pf i i urance earner and Pol crc
Policy number a .
Cv
rriCJ/ lU/VI0 Policy No ' 150; /117A_ b�TU _ ... _ ... . _
'CERTIFICATION l,I WORKERS
COMPENSATION
COMPENSATIONINSURANCE
(TM1is section need not be omplc¢d i!the permit is for one M1undmd dollars
s:
` I c n fy,that in he perf rte mit op the work for which this peris i sued,1 ... _ . . .. ... .,..,r.
em
shall oat ploy any person to any meso.,so as to become subject m the w'oikeri ,
Compensation Laws of California.Dae -
Applicant -NOTICE comesubject
APPLICANT.Work If.n's atom making this Cenwits ncaof of Exemption,you should
Qbebomesubjecty id Waith Compensation provisions of the Labor Costa,you must
forthwith comply with such provisions or this permit shall the deemed revoked.
CONSTRUCTION LENDING AGENCY
ZZy ' 1 hereby affimt that mere is a construction lending agency for the pefonnarce
of me work jot which his permit is issued(Sec.3097.Civ,C.)
0. Q Lender's Name
�5 Z fender's Address:'
U I ecnify that I have read this application and sum that he above information is
4a I;y contact.1 agree to comply with all city and county ordinances and stake laws relating
� f) to Wilding conaruction,andhereby authorize representatives of this city to enter upon
meati e n t' d,c sus and ' ,mon,aon pas s /
>� (W) g t save. d 'fyadk plarmle: the Cit fCperi egmnat
W liabilities.judgmem.cost d expect s which. y my way tete g nn said
C.7-Z C,v +eq a ce of th i gof hispernit
'I IEA%f UN DI RS f4` )S ASD ILL COMPLY\LITH ALL NON POINT' Issued b ! Date
.. s Eat .n't"S y: / 3
12,(3-oA
sig Applicant . emr; DataRe-roofs
. HAZARDOUS MATERIALS DISCLOSURE I, ,
Will the applicant fur building occupant store or handle Wardens material .Type of Roof . . . .. - .. .. .
as dein d by the Cupen -Municipal Code Chapter 9.11 and the health and Safety '
Code.Satin 2553Aa71.
°'`s ; - °'. (,,,•, ` ' ) . All.roofs shall.be inspected,prior_to any roofing.material being installed. . . .,,
will;I"eap ,in mte
or ohuibdimgn&n....�.riseegmpnnem ,odc.hc,swhich If a roof is installed without first obtaining an inspection, I'agree.to'remove
emit hazardous air conmminams as defined by the Bay Area Air Quality Management
D...rich, all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.; .
l4 I have ream the hazardous mu¢rials requirements under Chapter 695 0l the
California Health&Safety Code.Sections 35505.25533 and 25534.1 understand that
if thd W ilding dos not earned,nave a tenant.that it is my responsibility to notify the
a f the ormi e prt which..in be It prior to issuance of a Certificate of
Occup, cv.
Signature of Applicant Date
Owner or aumnnxed agent J Date All roof coverings to be Class"B" or better