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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMyATION:
BUILDING ADDRISS:
•JZ6/I
PLRMIT NO.
11102 WILKINSON AV
Lt.
A11-5haNuMb>h
00070004
OWNI?R'S NAME:
M k Rb
APPLICATION SUR DAT 1!
07/05/2000
CHEW
656. , ikl6t
PHONE,:
SANITARY NO. CON 1801. NO.
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ARCHITFICIZISGINF.F.R:
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BUILDING PFRMI'I INFO
BLDG PLUMB , h1'
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LICENSHI) CON 'IRACiOR S DFCLARXI[ON
Job Description
1 berth, Minn mat I Can licensed under provisions of Chapter 9 (enmmeneing
with Section 70(Xpof Division Sol the tint inewand Pmfesiots Gde,und my beam,
is in toe cares and ease.
se Class Linn
RE -PIPE
[')are
Urs eI)CCLA
necurnscr's Decl.na n0N
I understand my plans shall he uwN as public mttord.s
Liccnal Professional ,
OWNER-BUILDI:R DECLARATION
1 heraby alirtm that 1 am exempt from the Contractor's License Law for she
rollowin"c t. l S,aiun 7031.5. Heti nd 1'mfcn m Cade, Any city o unty
which requires a permit fin wrolmet, obimprove, demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit o lie a signal statement
Sq. Ft. Floor Area
Valuation
thin he is wen,dipan,ai Ou I, prnv,...00l he Contracaor, license Lao, tehapior 0
(calmnencing with Section 7000) of Division 3 of the Business and Prols000, Cede)
$ 4900
or that he is exempt thercliota and the basis for the alleged exemption. Any violation
of Section 7031,5 by any applicaut r..nt "mmol ,ubl¢h the appllamn to civil an"I"
APN Number
Occupancy Type
flood marc than live hundred dollars (s51Xp.
35617075.00
❑1,usownet ofthe property. mitt,Inpinyecswid,wagesa%dtah%fmc,mhem,ati„n,
-
will do the work, and the ru,nue is not intended or ,Ifcred lin sale (Sec. 7("4,
Huxines.s and Profndons Code: The Contractors License Law docs not apply In an
Required Inspections
propetyWho nhld,n,imprnvcxeeon,endIn"dool1aeltvorehimself
none,ffm
202 — UNDERFLOOR PLUMBING
Or his owe employees. provided mal such improvement, arc mol intended or
Offered for sale. If, however. the building or improvement is sold within One yes of
301. — ROUGH PLUMBING
cnfnplelinn, the owner.hnJder will novo dm harden of pnoing mal he did not I Id ar
improm lmpmimsum.sale)
502 — FINAL PLUMBING ENERGY
❑ L a, fwncr nnlnn pmt+nr, teen e,aft.i,ely emttrnear, with licensed eomr'cta” In
507 — FINAL PLUMBING
construct the project (Sec.. 7(111. Imoness and I'ntfession.s Cocc:)'I'lie Contractor's
License Law due, and apply u, an neater of pmpeny who build, or improves mcrcan,
'
and who corrals for sett pruiedx with a centramor(n) licensed pursuunl do the
Contractor's License Law. -
❑ 1 um exempt under Sec. . It K P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
'
1 hereby ullirm under penally or Perjury one of the following declar tions,
❑ 1 have aad 1111 maiinam u CenlGeme of ComcOn ,, xlf-in-re for Worker,
Compemminn, u, pmvidcd In by Section 3700 oI the Labor Code, for be
perfOmence of the work for which thi< pemtit is issued.
}
❑ 1 have and will mnimxin Wader's Cnmpensalion Inefnnca as required by Section
37M1 of the laha Colo. fur he perlonaance of the wo 1, for which this permit i,
Issued. My W/�jy/Ao�r', /C�oym�/9� rwranee ca /(i( /�J�Pnl�ic/Y�numF'r are.
Cartiee_/_mss Policy Nn./=(,g(/�-
CERTIFICATION OF I!KRMPTION FROM WORKERS'
COMPFNSAIION INSURANCE
I "is section need mud he u,mplcmd if the permit is for one hundred dollars
IS IMP ar It".)
I ecrdify that in the perti nnunce of the work for which this permit is issued, I
,
%hull not employ any parson in any manner sea rix to Iwcoam ,uhlect Or the Worked'
Campenution Loos of Cnlifomio. Date
NO'HCH 10Niernmkinethisovisiosof of E,
odyouumulst
becomesubjctIntheWor:IL
the Labor Code.yfu mull
bcefinesu...opy me ,Compcn., provisions Labor
'
C,ehpker
his hdI
limhwith comply with .ash pnrvisionx nr his permit shall M devoted revoked.
CONS 'I'RUC [UN LENDING,wCNCY
I hotvmy aBimt nen mere Is a construction lending agency for the performance
01 the work lar welch this period h le.ued (Sc,,. 307. Cl, C.)
Lender's Name
Lenders Address
I certify that 1 have toad this application and state that the abuse information is
matt. I agnea to comply with all city and county ordinances and state laws relating
w 1`1111,11."consuucnon, and heehy aulhorite rep ra.conal e, at his city nn enter upon
the above -rand ma l property lin inspection purin%o.
(We) serve to save, indemnify and keep harmless the City of Cupsninn against
babilidox, judenncnt.. cast% and expanse' which may in airy way aKmc again"'aid
City in consequence Of the graming of this permit.✓>/
O Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONLPOINT
Issued by: Date
y'
SOURCE REGULATIONS.
Re -roofs
signmurcof ApprcanvGtntrac o, Date
HAZARDOUS MAA ENRIALS D1SCi OSURH
Will the applicant or future building accuem,RIOne OF handle hazardous numenal
Type of Roof
as defined by the Cupertino Municipal Code, Chapter 912, and the Ilealth and Safety
Code, Section 45532(0'1
O rc% ONn
All roofs shall be inspected prior to any roofing material being installed.
Will meopplicain or Bnture hmld'ntheneenipam a,n egon",e, nrdcvlccs which
If roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminates as defined by the Buy Area Air,Quolidy Management
Distde7
all new materials for inspection. Applicant understands and will comply with
7Ye% El No
all non -point source regulations.
1 have read the hmr,mlia, materials requimmems under Chapter 6.95 of the
California Hndth A Safety Code, Seeuoo125,5115.25,5)3 and 25534. 1 undersumd ,hal
if the building docs not cumendv have a femur. that it is my re,onsihilidy to notify the
Occupant of the requimnems which must be met prior to issuance of a Cenilicade of
Eo
DCCCCc''
Signature of Applicant Date
All roof coverings to be Class "B" or better
DwnerarDato
Call mii.edagent
OFFICE