02110146 (2) CITY OF CUPER7'INO .#yr'JOR tr',4 �r;.
BUILDING DIVISION PERMIT %CONTRACTINFORMATION
Bulf2l1gA1I8ESY2ED FIR CT KEITH GARVINE PERMIT W02110146
GWNf�N MICHAEL E AND RITA A 3077 ZION LANE APPLICATI1NtS"n5V2002
ONE: (408) 259-7874 SANITARY NO. // LL CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C 0 0 0
tilO0 LICENSED CONTRACTOR'S DECLARATION
zuF IherebyaffirmthatIamlicensedunderprevisionsofChapter9(commencing COPPER REPIPE Job Description
5<i with Section 71XID)ef Division Sof the Businessmul Professions Codc,and my license is
t_ow mlull forccand effect. R �Lal�lO� ALE®
ZOY? License Class L"x"-l.ic.N
2z Fn Dam I�7. Comncmr G' -
���'t'�ty AHC 1'IT:CI'S EC ION
"'� IunJe Farad ypla a tall W nae .Itibh ce ��7 JAN 0 2003
LLC Lic IU n V alted
—/�-
OWNFindexemptiR RAtTION BUILDING
<I 1 hcrchy allirm that um exempt Intro the Cnntrannr's Liccnm Law for,hc �5 0 0 0
�a
00 following rectum.Senior 7031.5,B.Arwis and Pmfo,e...s Cede:Any city erectility
K$� which requires a permit set cnn thin,alter,improve,demolish,or repair any structure
ytu.3i pdnr In its issuance,also requires the applicant ter such Permit o file a signed statement
g�Q
that he is liccused pursuant In the provisions of the Comruclor a License Law(Charter 9 33�M.ffft1}Ar0t0 Valuation
22 (commencing with Section 7000)Of Division 3 of[be B uslness and Professions Code)it
a,03$ that he is exempt therefrom and me basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of PN-N Occupancy Type
no,mem than rnVObandied dollars(S500). 202 — UNDERFLOOR UMBING P y yp
I,as owner Of the property,or my employees with wages as their side compensation,
will do the work,and the structure is net intended or offered for sale,sec.7044,Business — �p
and Professions Code:The Contramers License Law docs not apply m an owner of 3 02 - TUB Tic I('ug lISBCGIIOHS
property who builds or improves themen,and who does such work himself orthrough his WW ttCC
own employees,provided that such improvements arc not intended or offered for We.If, 502 — FINAL PLUMBING ENERGY
however,the building or improvement is sold within one year of completion,the owner-
buimer ,will have the burden of proving mat he did not baud or improve for purpose of 506 — GAS TEST
sale) 507 — FINAL PLUMBING
1,as owner of the progeny,am exclusively contracting wit licensed contractors to
consumer the pmjcet(Sec.7144,Busine,and Professions Cocks The Contractors Li- .
u Law does not apply to an Owner of progeny who Wilds or improves thereon,antl,
who comment for such projects wit a commator(s)licensed pursuant to the Contractors
License Law.
l am exempt under Sale. ,B&PC for this rcazon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury oro of she following declarations:
1 have and will maintain aCertifcate of Consent m ulGimure for Worker's ComNn
737M
mon,as provided for by Section 3701 of the LOW,Csde.for Rm Per(omnance of,he
rk for which suis Permit is issues.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Cole,for the Performance of the work for which this Permit is issued.
y Worker's Compensation Insurancecarrier and Policy numvb�err am �rrrler::5'�'LI"j'C %V/ Policy Na.:7hffl�✓I�///T /4'LI --
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE
(This section neca not be completed him Permit Ls lin one hundred dellam($100)
or[as,,.)
1 cenifr the,in In.Performance nl'the work lin which this Permit is Issued,I shall had
employ any Person in any manner to as to Wuomc subjectto the WorkersCompensation
Laws of California.Data
Applies.,
NOTICE TO APPLICA Nr:If,alter making this Ccnilicae of Exemption,you shoo lJ
become subject to the Worker's Compensation provisions of the labor Cuda,you must
OO (orthwith comply with such provisions tar this Permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hcrchy affirm mat there is a vonsmacom lending agency lor the Performance of
tY me work for which this Permit is issued(Sac.31N7.Civ.C.)
IT] Q Lcndcr's Name
O.a Lender's Address
Z) z
U 1 certify that 1 have read this application and suite that he aWvc information is
U. 0 butmingcomeemco,andmply withyauthori county of this sum tawsreadingupongm
0 building ranee to co and with all
leity and come ordinances
city 1.ws r actin to
above-mentioned propeny for inspection purfosi nes. .J
1 (We)ag I save•iolcmmfy d kec hmmless Ibe 0ity of Cupertino against Icy
In liebilities,judg nu,cos, bd open swhic may in any way acemc against said City
Uz in co
free gm ingu(th',
APP CA UNDER AND D L OMPLY WITH ALL NON-POINT Issued by: Date / J
SOU CE,. TI S
145'61
.2 Re-roofs
�r' i at of P aHAZARaz1 USM TA,p DISCLOSURE Data Type of Roof
ill the applicant or fu tsi gnecupam esus sur handle haauduusmaeriel
as dein by the Cupertino Municipal Cade,Chapmr 9.13,and the Health and Safety
cads. W325332(.)'0All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant er futon doing Occupant use cyuipmenl at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? ss5sss��a��a
❑Yes \f�I No ,
Ikvc mud lh tit. JuCs\inicrials to mcnkvmJcrChapmrfi.95elthe Cali Bn-
niaHcalWda,Eafcty adc,ScctiO s255115, 53.mJ 25534.1 undardand mal if the building
eats nor ca all Ifivc n tun' t,that II' my cart^xinili,y to nollly tW ttcuPant nl Nc
recut rcm sew it rust et PAitr iisn nceofa Cenificmaf Occ�ancy.
I Signature of Applicant Date
J I SV ta
0 cr 0 u � Data
All roof coverings to be Class "B"or better
y