02110008 (2) CITY OF CUPERTINO -.+x -'.rix
BUILDING DIVISION PERMIT �.CONTRACTORINFORMATION:x
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HDIgIpIQAP9ES7ISTA CT CUPERTINO PLUMBING PERM11N02110008
GwKT0F LDT MARY S TRUSTEE 10297 S DE ANZA BLV APPLICATTIsy1ITY2002
IONS: (408) 253-0618 SANITARY NO. CONTROL NO.
I
ARCH1=1ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑s, �7 0 i�
Poo LICENSED CONTRACTOR'S DECLARATION
I hcrehy motion that I am licensed under provisions of Chapter 9(commencing Job Description
win Section 70po1pfDivisom 3 of the Business and ProfcasionsCode,and my license is WATER SERVICE
rOw infua font and,
ZOq� License Class 1.iaN_ISE � 1 � FINALED
�Z y n Date 2 Contrunnr I/l�'
ARCIII'HIC1"SDECLA NHON
Y��-s I nnleratanJ my plans shall W usod as PuNic records ,
APR 14 2003
LLO� Licensed Prnfcssi...I
g OWNER-BUILDER DECLARATION
wFy I hereby affirm that 1 em exempt from the Contractor's License Law for the �..p-n1�sv vs
p 0 following mason.(Section 7031.5,Business and Professions Code:Any city Or county r V Y,A
w$K which requires ma permit to construct,alter,improve,demolish,or repair any structure
poor to as issuance,also requires the applicant for such permit to file a signed statement
�PPiS< that he is l icensed pursuant to the previsions OF the Contractors License Law(Chapter 9 3SW61KID(MAaO Valuation
C t'S (commencing with Section 711111))of Division 3 of the Business and Professions Code)or
— that he is exempt therefrom end the basis for the alleged exemption.Any violation Of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penally of i UAPN N Occupancy Type
n0 mon than rive handled dollar,($500), 202 - UNDERFLOOR PLUMBING
P Y YP
❑1,as owner of Ne properly,or my employees with wages as their sole compensation,
will do the work,and the s(ructum is not intended or offered far sale(Sec.7104,BusinessU}r
and Professions Code:The Contractors License law does not apply to an owner of 302 - TUB a q p tions
property who builds or improves thereon,and whodoes such work himself or through his
man employees.provided that such improvements uenot intended or offered for sole.If, 502 - FINAL PLUMBING ENERGY
however,the building or improvement is mid within one yxsr of completion,the owner-
builder will ban the burden of proving that he did not W old or improve for purpose of 506 - GAS TEST
.to) 507 - FINAL PLUMBING
❑1,as owner of the property,am exclusively contracting with licensed contractors to
ConsWct the project(Sea 7M ,Business and Professions Code:)The Contractor's Li-
ensc law does not apply to an owner of property who Wilds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law,
❑1 em exempt antler Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION I
1 hereby affirm under penalty of perjury one of Ne following declarations:
❑ I bare and will maintain a Cenifcate of Consent to self insure for Worker's Compete
station,a;provided for by Section 37118 of the IaWr Code,for Ne Performance of the
walk for which Nis Permit is issued.
❑ 1 have and will maintain Worker's Compensation Issuance,u required by Section
3701 of the Labor Code,for No performance of the work for which this permit Is issued.
My Worker's Compensation Insanes carti,,rud Policy unbeoare:
Carrier: r-r �dN Policy No: 71301 VNt-r
CERTIFICATE OF EXEMPTION FRO ORKERTOCX 7UOgp
COMPENSATION INSURANCE
Fr ossection need nal Ixcnmplowd if the Permit is forms,hundred dollars(5100
or less.)
I cenify that in the performance Of the work for which this Permit is issued,1 shall not
employ any Person in any manner sat as to become subject o the Workers'Compensation
Laws of California.Date
APPIMLM
NOTICE TO APPLICANT:11,alter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the lahor Code,you must
� Z forthwith comply with such povionns or this Permit shall W deemed mvnked,
z O CONSTRUCTION LENDING AGENCY
[-+ hereby affirm that them is a construction lending agency for the performance of
�. 5thewukfor which this permit is issued(Sec.3097,Civ.C.)
`25 Lender's Nam.
Z Lcndch Address
V C) I comfy that I have read this application and state that the above information is
(L F cmmet.1 agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby suhnriac representatives of this city m enter upmu the
above-mentioned property for inspection purposes.
(Wo)agree hs save,indom sly end keep armless the City of Cupertino against
LI) I'llitics,judgmcnu,co mMae nxs ich my in any way mane against said City
in Za.ucncco c ,min f'isW�
U APPLICANT RSTA S WOM WITH ALL NON-POINT Issued by: Date /
SOURCER U TI N i'
Re-roofs
o plat HAZARDOUS DISCLOSURE Date Type of Roof
will the applicant of future Wilding occupant store or handle bamdous material
as dcfncd by the CuKrurm Muni pal Cod.,Chapter 9.13,and the Health and Safely
Code.Section 25532(a)'
0 Yes o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Town building Occupant use equipment ser devices which If a roof is installed without first obtaining an inspection,I agree to remove
,mil hezaNnus air Comamio no,as di fined by the Bey Area Ail Quality Manegcnem all new materials for inspection.
Diihictl
❑Yes No
have in rardn maters ley ' mcntsundcrchapter695ufNeCalifor-
awllcalth& ly ide.Sec oou ,355. 125534, n4crstM bu
enddeniftilding
docs not cu qa m ant, et reffi y u notify the tacuPanl of the
require in w must m mi, is
Pme r - heaatofQ:euPen,y. Signature of Applicant Date
Ownuorim if e gen V VDate All roof coverings to be Class"B" or better