07100081 REV1 CITl' OF CUPERTINO < ' - - !
BUILDING DIVISION PERMIT ���t'����Tt�1R, I�Y�(?R��TIQN` .;
BIJI[.DING ADDRESS: PERMIT NO.
� 2 4 4 5�C''U���m��I�—�� '
ER'S NAME: p
PHON . , S CON'IROL NO.
ARCHITEC'i/ENGINEER: BUILDING PERMfI' INPO
BLDC ELECT PLUMB MECH
. G O 0 0
: p LICENSED CONT[tACTOR'S DECLARATION
�� 1 hcrcby afGrm that I am Iiccnsed undcr provisions oC Chaptcr 9(commencing Job Description
: � wi�h Sccuon 700()) of Division 3 of thc Busincss and Protcssiuns Codc, and my liccnsc is
� h in full torcc and cffec�
;? LicenscCl 6 L��.0 SG`f'7 _ REVISICN-INSTALL SEWER PUMP AT KITCHEN.
� �am>o�2- _�co��rac�ur � �KL-_ ��?/�--- - �ORIG #C7040009 NEW PERMIT
: � ' ARCHITECI'S DECLARATION
%� 1 undcrstanJ my plans shall bc uscd as puAiic rcrnrds
� Licenscd Pcn(cssional
� N OW NER-BUILDER DECLARATION
o�
t� 1 hcrcby aClirm that 1 am cxcmp� from thc Contractor's Liccnsc Law for thc
� O foliowing rcazon. (Scction 7Q31.5, Busincss and Ptnfc.ssions Codc: Any city or counry
;� which rcquiccs a permit ta cnnswc4 al�cr, improvc, dcmoiish, or repair any structure
;} priot to i1s issuance, also rcquircs thc applicant for such pertnit to filc a signcd sta�mcn�
�< that hc is liccnscd pursuant to Ihc provisions o( �hc Cnntracwr's Liccnsc Law (Chaptcr 9 ;>q . Ft. Floor Area Valuation
-� (commcncing wilh Scction 7000) o! Division 3 of lhe Busincss and Rofcssions Codc) or
L.. that he is exempt Nemfrom and the bazis for �e allcgcd ezemption. Any violation oC
Section 7031.5 by a�ry applicant for a permit subjec�s ihe applicant to a civil pcnalty of APN Number OCCIl 1I1C T
not more than five hundred dollars (5500). P }� }��
� I, ss owner o[ the propcny, or my employces with wages az the'v sole compensadon, 3 2 61512 9. 0 0
will do �he work, and the structure is not intendcd or oftered forsalc (Sa. 7044, Business
and Professions Codc: The Conuactor's License Law docs not apply to an owner of Required Inspections
property who builds ot improves thercon, and who does such work himulf or theough his
own employccs, provided that such improvemenls are not iMended or oEfered for sala iC,
hawever, lhe building or improvement is sold within one year of wmplction, ihe owncr-
builder will have the burden oC proving �hat he did not build or improve for purpou of
sak.).
❑ I, as awner of the property, am ezctusively conuacting with licensed rnnvactors to
conswct the projett (Sec. 7044, Business and Professions Code:)'I7ie Contracwr's Li-
cense Law docs wt apply �o an owna of property who builds or improves �hercon, and ,
who contracts for such pmjects with a con�ractor(s) ticensed pursuant w ihe Convactor's
License Law.
❑ I am exempt undu Sec , B& P C for �his reason
er Date
WORKER'S COMPENSATION DECLARATION
I 6ereby affinn under penalty of peryury onc of �he following declarations:
❑! hsve and will maimain a CcniGcate ot Conscnt to self-insure for Workcr's Compen-
sstion, u providcd for by Sec[ion 3700 of the Labor Code, for �e pedormance o[ �hc
work Cor which Ihis pertnit is issucd.
❑ I havc and will maintain Workcr's Compensation Insurena, as rcquired by SccUon
3700 oC the Labor Code, for thc pedormance ot the work for which this permit is issued. '
My Workers Compensarion insurance carticr and Policy number arc:
Cartier. Polity No.:
CERTIfICA7'E OF EXFMPIION FROM WORKERS'
COMPENSA'CION INSURANCE
(This secuon necd not be completed if the pecmit is for onc hundicd dollars (S 100)
or Icss.)
i cenify that in thc performancc af ihc work for which this permit is issucd, ! shall not
employ any person in any manncr as to oq�c subject to the Workcrs' Compcnsadon
Laws of Calif �a, palc a .O f
Applicant � u-
NOTICE 7'O APPLICAM: !f, ahcr making this CcrtiGca�c of Ezcmp�ion, you should
ticcome subject �o �he Worker's Compcnsauon provisions of thc Labor Codc, you must
� O faMwith comply with such provisions or [his pecmit shal] bc dccmcd revokcd.
� � CONSfRUCI'lON LENDING AGENCY
�►� 1 hercby amrm �hat Urcre is a conswction Icnding agcncy for thc performancc of
i� thc work for which �his permit is issucd (Scc. 3097, Civ. C.)
� Q L.endcr's Namc
� z L.cnder's Address '
) Q I certify Ihat I havc rcad this applicauon and state that the above informauun is
►-� cortec� I agree to comply with all city and county oNinances and state laws reladng to
j U building consuuction, and hcreby auUioritt rcprcscntativcs ot ihis city to cntcr u�mn �hc �
W aMvc-mcnGoncd property for inspcclion purposes.
� (Wc) agree �o save, indcmnify and kecp harmless the Ciry of Cupertino against
;� liabililiu, judgmenLt, cos�s and expenses which may in any way accruc against said City
) Z in consequence oC thc granting of ihis permit. '
""� APPLICANT UNDERS'fANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �� — Z�'� ��
SOURCE REGULATIONS. �i �,/
�-� —� / `� 2 �/ a7 Re-roofs
Signature of ApplicanVContractor Da4
HAZARDOUS MATERIALS DISCLOSURE Type of Roc,f I �����
�11 Ihc applicant or fuwrc building occupant storc or handlc ha•rardous matcrial
dcfincd by the Cupenino Municipal Codc. Chaptcr 9.12, and thc Hcal�h and Safcty
:c, Scction 25532(a)? All roofs shall be ins ected nor to an roofin material bein installed.
❑ vcs l�j'tvo P P Y g P�
' If a roof is installed without first obtaining an inspection, I agree to remove
Will �hc applicant or futurc building occupant usc cyuipmcnt or Jcvices which
cmit hazardous air contaminan�s as dcfincd hy the Bay Area Air Quality Managcmcnt all new mat °rials for inspection.
D�:U;��� '
Q Ycs �Nu
�'
1 havc rcad the ha�ardnus ma�crials requircmcnts uncicr Chap�cr 6.45 of ihc Califor-
nia Hcal�h & Safcty Codc, Sectiont 25505, 25533 and 25534. I undcrs�and �haz iCthc building
docs not curtcntly havc a �cnan4 �hat it is my rcsponsibiliry io notiCy Ux occupant of ihc
rcyuircmcn�s which musi bc met prior w'ssuance o[ a Ccnifica�c of Occupancy. StgtlBtUrC Of AppIlCallt Date
�� � �' Alt roof coverings to be Class "B" or better
Owncr or authorizcd agcnt Datc