01050113 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10315 VIRGINIA SWAN PL BUDGET PLUMBING 0105011.3
OWNER'S NAME: . APPLICATION SUR DATE
HOSHIZAFI hiCAD00 28695 ROANOKE ST 05/14/2001
PHONE: SANITARY NO, CONTROL NO.
(51.0) 303-7847
C,re AItCI II'I PC'I II!NGINLER: BUILDING PHRMI'IINFO
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S°Z LICENSE CONDPRACfORS DECLARATION - Job Description
✓m I hereby affirm that 1 am licensed under provision..of Chapmr 9(Commercial,
0wf-m with Section 7ggpnf Division 3.(the Harmines and Professions Code.and my license
at °"rnr°°°^°`m WATER HEATER REPLACEMENT.
C,5 a Liecnm Class law g
°n O Dae Contractor
ac2 O t; ARCHITECT'S DECLARATION
g1 understand my plans shall be used as public records
rea Liccr al Pndnsiand
% OWNER-BUILDER DI!me RAI ION
Cootimair
W I hereby alarm that I um umnpl lion,the Cnn.mabr'sLicense: Law for the
to
following moon.fenrit ,7en L5, %at,e.s and 1'rufchxions Cuda Any city of orI,
I F O prix t. I .. t Ct h J I'h i 0 Y structure
t
prat t er c I y Pr rel If u 'tt II -6 Ja rncm
moo leaned pursuantu d Provisions of the
Ind 1 L ICnuphr9 Sq. Fl. Floor Area Valuation
in hat he
with therefionrom
om and
ue basin 3 of,a 0,ede a and PmfA.ons Gclnl
or Sec he is exempt Iany affluent
and or pro for the alleged cacmption.Any violation $600
of nor more
a th n v any applicant for a pemnin subjects the appli<am IDI a civil Penalty
of nm mare man m�r hundred annar.fsstgn. APN Number Occupancy Type
O 1.as owner of property.or my employees with aages as their sole compensation. 3 1 EAF,01
will Jo the ants,and me structure is not intended or opired file sale(Sec.70sl
Business and Professions Cale:lee Contractors License Law does not apply to an Required Inspections
ow r of property Who builds or improves thereon,and who does such work himself
or through his own a^physes.provided that such improvemens am not intended or 5022 — FINAL PLUMBING ENERGY
offered for sale,It,however,me building or improvement is sold within one year of
....... ,If have dm barren f proving that he did not build or 506 — GAS TEST
intprose lot pmpn.oil.ale.). 507 — FINAL PLUMBING'
❑I,as owner of the"open"ant ts'Ifo,cly uonaacting win,Beamed coulnntots or
n.tmct the au,w IScc.7W4,0th Isi and Ir... . tax Crdsc:)The Connorrat
.......
a law does nm apply m nn cis W of propesy Loon solids mrd par a thio the
and who amrman for such pmjecu xdN n unnr:mmrfs)licensed pursuant m the
CoI m cimi Liconde Sec.I rat e¢nnpl under Sec. .H 8 P C for this mmnn '
owner Dam
WORKER'S COMPENSATION DECLARATION FL�m B A LGA
I hereby affirm under penalty of perjury one of the following derbrmions: Y ' /Y G
0 1 have tuts will maintain a Cenilicam of Consent to self-Inoue for Worker's OCT 15 2001
Compsnouin 1, as provided for by Section 5700 01' the Labor Calc, for the
,,hula ance of the work for which this permit is Issued.
❑I have n I will mainnin Worker's Cmnpen,ru al Insurunee,as rcynired by Secunn BUILDING
9700 ill tits Labor Codetar thePertor wo
el the rk fit which his pet nit Is
antro
natal.My Worker's Cninlu7nxminn Innurunec currier and Polley noinbsr are
Carrier: Poi,,No-
Clik1'IPICATION OR ENEMITION PROM WORKERS'
COMPENSATION INSURANCE
(Phis section need sol he completed if the permit is for one hundred dollars
IS I W)or less.)
I ccr ify tbar in the performance of the work fir which this permit i.issue 1.1
shall not employ any person in any manner so as ,,heroine subject na the Workers
Compeavation Laws of Califoaia.Dam
Applicant
Not TO APPLICANT:If,alcor making els Cenhicate of Exemption,you should
beano subject to the Worker's Compensation provisions of the Labor Cade,you moa
Q O umlood,"amply with such provid; or thio permit shall be dea and revoked.
FCONST RUC9'ION LENDING AGENCY
CG I I...rhy allirm that Iarm is a mnsmminn Icnding agcnry Em the prrll...mace
if work for which this penmt is issued(Sec.3097.civ.C.)
O. Q tenor'.Name
D z Lender's Address
U Q 1 certify that 1 have mad this application and sate that the above information is
correct.1"mom comply with all city and county o simmu cs and state laws mining
Q U to building Construction.and hereby aumorire representatives of this city to enter upon
the abrvumentianed properly for impcetion puHe,ws.
t.. a (We)agree ,save.indemdryand keep harmless the City ofCuetinuagainst
Ud Iia h
hill ties,judgments,costs and expenses which any in any way accrue against said
U Z coy in amxequencc of the granting of this potion.
APPLICANT UNDERSTANDS AND WILL COMPLY WI"rH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, y'
Signtarell AppdeanllCammeor Dare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicam or future building a ay,unt store or hurdle hazardomtnaerial Type of Roof
as defined by circ Cupenion Municipal Codc,Chapter 9.12,and me Health and Safety
Code.Seen255}2(°)? 0N
All roofs shall be inspected prior to any roofing material being installed.
Will he applicant orfair.building«enpamnmrynipmentirde,ices xmich If a roof is installed without first obtaining an inspection, I agree to remove
emit formations air Concomitants as defined by the pay Area Air Quality Management
Di.ma7 all new materials for inspection. Applicant understands and will comply with
. GYes 0N all non-point source regulations.
1 have read the hazardous materials rajoirtmems under Chapter 6,95 of the
Cal fornix Health Pc Safety Cori Sections 255115.25577 and 25534.1 understand that
il'Ibc Funding docs rnr c rm nlly bre a mrn 1.thin it is my respnmibiloy tan tori ly the
«opanl of[lie maul rement which rest he tact prior m issuance of a Cerareaa of
occupm ..y
. Signature of Applicant Date
Dwaernrandoodrelageat Date All roof coverings to be Class"B"or better
OFFICE