03030069 CI TY OFCUPERTINO >�;w� p ..irf :uwa""»§rtfi^Itxara+,msa�i;;ft�-= '
BUILDING DIVISION PERMIT �i\sl.UC°TQW IN FOM'4I ,N -
RUILDING ADDRESS: - PERMIT NO, .. -
OWNER'S NAME: PER'N117
ALAN D
iE: - SANITARY NO. OL NO.
ARCHITECI'/BNOINEER: "' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACIOR'S DECLARATION .lob Description -
1 hereby of on that 1 em licensed under provisions of Chapter 9(commencing
Zl with Section 70(10)of Division 3 or the Business and profeuuns Code,and my license Is.
mmn �'����®
Licell f ClicLie.M
n m¢aandnrR" EP
ADD GAS LINE TO FIRCE
��Z
— Date Contractor
ARCHITECTS DECLARATION APR 0 2 2003
Q 1 unckn and my plans shall W a used public records -
5 Licensed Professional (
E rollnwing.reawn. OWNER-BUILDER DECLARATION
I hereby affim at1amexempt from hContractors License law for M BUILDING
to O (Section 7(013,
-
Business and Rvfasdna Colo:Any shy or county
$�i which acqulra a permit a construct.alar,improv.demolish.or repair any structure
l' prior to ire issuance,also resinous line applicant forauch permit a file a signed statement< thatW is licensed pursuant to the provisions or the Contractors License iaw(Chapur9 Sq.Ft.Floor Area _ �uetlOn
ell (commencing with Section 7M)of Division 3 of the Bmuoasand Profession Coda)of
Q 33 that he is exempt Reef om and the bait for the alleged exemption.Any violation of I,,
Section 7031.5 by arty applicant for a permit subject,the applicant to a civil penalty or 3A p�-J)J�7 W9* 00 Occupancy Type .
not mom Nan five hundred dollars(SM
❑1,as owner or the property,a my employees with wages u tbelr win compenudon,
will do Ne work,and ommuncum,is not Intended or offered fonalc(See.71144.Budmas 106 SEWER Ria "IYUPpecti
and Points on.Code:The Contractors License Law docs not apply be an owner of b idons
„
property who buildaorimprovesthereon,and whodoessuchwork hlmselfor through his - 202 - UNDERFLOOR 'PLUMBING
own employna,provided that such Improvements are not nunded proffered for al.If. 301 — ROUGH PLUMBING
however,the building or impwvemrnt is veld within one year ofww
mpledon.the wetness.
_ -
builderwillhavetheburdwofprovingtluthedidnotWimarimproe,forpurytueof 302 — TUB- &'OR SHOWER -
ale.). - .
u owner of the property,am exeludwIy mommcting with licensed contractors m 502 — FINAL NAL -PLUMBING ENERGY
annct the pmjed(see.7064.Eus ilea and Profations Code:)The Conmctors LI- , '506 _ GAS TESTI
melaw does not apply in an owner of property who Wilda or improves lhemen.and, '507 FINAL PLUMBING
who contracts for such po jeda with a memorial licensed pursuant u the Contractors LicenseLaw.
❑lam exempt under - ,B&PCfallu...
oat.,../ 2 �
RKER'S COMPENSATIOO N DECLA N
I herchy affirm under peachy or perjury ane of the following dwI allow, - -
haw and will malnuln a CWBnu ofCoaenuo alf-Imum Eaworkees Compen- -
satun.u provided for by Section 3700 of the Ube,Code,for the performance of the
work for which this permit is sauce. -
❑1 haw and will maintain Workers Compensation Insurance,m acquired by Section -
3700 of the Labor Code,for the performance of due work for which this permit is Intend.
My Worker's Compensation Insurance carter and Policy number em:
Cartier. Policy No.:
CERTIFICATE OF PXEMPfION FROM WORKERS'
COMPENSATION INSU RANCE -(This section need not he completed if the permit is far me hundred dollars($](XI) -
or less.)
I wni(y th In Ne rfo e"M of the work for which this permit is Issued,I shall not
employ anyap�c,oJZ �anymanmrwuuW rouble lmthe wodufs'Compeaaflon
Laws of Celifonda.Date -
APPLICANT:IL after making this onfiriciac of Exemption,yod thou
become subject to the Worker,Compensation provisions of the labor Code,you mud
z foMwole comply with such previsions or this permit shall W doomed revoked.
„z„O CONSTRUCTION LENDING AGENCY
1—t 4 -I hereby affirm that them is a construction lending agency for the performance of
f8 r7 the work for which this permit is issued(Sec.3097,Civ.C.)
fg1 Q Lnndce.Name
.7 z Lender's Address
V Q I eedify that 1 have mad this application atm state Nd the above Information is -
F correct.l agree to comply with all city and county ondinanns and sure laws relating to
QU building construction,and hereby Authorise,representatives of this city to enter upon Ute
[sl above-mentioned property for Inspection purposes -
Ly,G (We)ague he low,indemnify and keep hermlau the City of Cupenino age _
it N Ilebili0u,judgmenu,costs and expenses which may In any way acme against said City
U 7 in consequence or the granting of this permit. �J /
F7 APPLICANT UNDERSTANDS AND WILL COMPLY Wm[,AL AL N-Poles Issued by:9 -Date /
SOUR EREGULA
Re-roofs
S .dart of APP t ✓Contactor t Dale
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future building occupant or hand],haardous material
a defined by the Cupertino Municipal Code,Chapter 9.12.and the.Health and Safety -
cdc.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya o,
Will the applicant fuurc building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It ha"nous air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. :
WHM7 -
Ye.
❑ ` /tu .
IhavcrtW Ne hila orCmm.mriai.mquimmenuundcr Chtpwr6.95orf Glifo,- '
nit Health&SafetyCod,S =25N)5,25533md235N.lundeJulif Wild'us
does mol curently haw a tenant.thd It is my rcspmuuillty m non to pact nr rose
emu which el pdorulauance ora CcniOnteof ` Signature of Applicant Date
4 "3 All roof coverings to be Class "B"or better
Owner or wt xeJ gent 6.w