00100190CITY OF CUPERTINO
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BUILDING Dtvtsion
PERMIT
_ CONTRACT.ORF INFORMATION:;;';
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BUILD ING ADDIi ILSS; -
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PERMIT NO
OWNER'S N
APPLICATION Eft', J
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SANITARY O,
ARCHHTgCT /CNGINEER:'
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'HUILDING PERMIT INP(1
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ELECT PLUMB MECH
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' LICENSED CONTRACTOR'S DECLARATION
Job Descri tlon
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1 lac clay of irm that I am licensed under provisions of Chapter 9 (commencing
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3 wdb Sired l 71Nllp .I'Ilivl %inn3ol' the Business and Proc,,si.nx(:od,. and any In,enw,
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a . in Ball force and elfecl.•
` I).eenwGla%,, Cent
Uzlc Convenor
REPLACE-40 GALLON GAS WATER HEATER
o ARCHITECI "S. DECLARATION
5 I .Odeon nd my plans shall he used as public records
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Licensed Prafess.omal
OWNER - BUILDER DECLARATION
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1 herehy ulfiml 111.1 1 am exnnpt from the Comractur's License Law for the
[ ....awing reason, Iseclien 7031.5. business and Professions Code: Any city nr outlay
] which reunions a permit to conoract, alter, improve, demolish, nr repair any htrnumrc
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pnor m ion Issuance,.. - retlme, the nppl leant IOr roilh permit m lilt n nqm d antenna,
- thal he is licensed p.,.ammme pr ixitm of du C.mmcmrs Lima, Law Chapala- 9
S4. Ft. Flood- Area ..
Valuation
mmemcacing will Section 70(10) of Division 3 of the Bmimcss and Profession Code)
mutual he is exempt thcmfrom and the basis for abe alleged 6,rnaplit n. Any violation
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o.Seeion 7031.5 hy.ny applicant Toren permit subjects the applicant m a civil penalty
.root moat loan rvehanareddollars (s5(a).
APN Number: -
Occu a pe '
❑ 1, as Owner of the projam y. omny nnployees with wages as their vole compensation,
will Jo the work, and the seor om is not intended .r oRertvl for sale (Sec. 70,W,
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Business and Pr.fessrora Code: The Contractor'., License Law does not apply to an
"-'' ,. .. quired Inspections
owner of pmpeny Who builds or improves thereon, and who dons such work himself
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,,, I rough his own eanlloyeea, pnavidnl that such Impn.vemeus am not ,identical or
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left 'e..it ter ime. If. h.w.v to, Ih. budding or lnq,a %rvcnnot is ... Id within one year or
502 — FINAL. PLUMB ING ENERGY
completion. the owner - budder will have the much Of proving that he did not build or
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.npmveforp.ryasuo a)e.).
506 — GAS TEST
❑ 1, as (owner of property. ant exclusively contracting with licensed contractor. m
507 — FINAL PLUMBING
morel the Tom,, (See 7044, 11 alms nnJ,Prnre %%Inn% Ga1c:) The Conuvclor v
License law does 'all apply m an owner of pmpeny who huild, a, improves Italian.
and who commas for such projects with a contracna(%) licensed pursuant to the
Contractors License lase.
❑ I am exempt under See. , B k P C for this mason
.Owner Dam
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' WUItKF:R'S COMItiNSA'I'ION UECLARAI' ION '
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I hereby affirm under penalty lay I per) , One of the following J slat ai n:
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kI h d II aunaC if a, t C t t . If ref Wk 's
Cm Tionann d In by Section 9700 it f the Lativer Code, let the
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'parfuninative of the work for which lhi% entails issued
❑ 1 have and will maintain worker'% Compensation Insurance, as mr,med by Section
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371X1 or the Labor Cade, for the performance oT the work for which this permit is
issued. My Worker's Compensation Insurance carrier and Policy number are:
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Carrico Policy No.:
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CERriTCATION 01; EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
(This mconm need nnf be cortuned if the Ismail is fn, one hundred dollutx
tOlkinrles,,d. -
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1 verify that in the panf mawdc of the work for which this permit is issued, 1
shall not employ any person in any zinnancr so as m become subject to the Work om
Cnmpcnxmion Laws .f Culifomia Dtta,,
A,Aan
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'NOIICE'TO APPLICANT :if, slternwkinglhi% CO(dicate.1 U.nodio., Y ,it, ehuulJ
heron, subject to the Worker s Conq,ema.on provision,, of the laMm Code, you anon
forhwith comply with such provisions or this permit shall be dmned•revoked.
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CONSTRUCTION LENDINGAGENCY
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I hereby nllinn .hilt there Is a c.nswcdnn lending agoncy Vv the perfmnntice-
of Ibe work f)r whirl, tl .l. p.. and i, issued (Sec. 3097. Civ. C.)
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Leader's Name
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Lenders Address
I anify that l have read this staff ication and sums that the above information is
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" "mcl. I agree m 'and, with all city E I county nnhounice, i I sat, laws ml'iling
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m hadchngc.mlm, non. and hereby aulhmizempre ,cmdi , rs of (his day to scale, .,,,a
me alwve- m.nli.ned pmpeny ter im iticed on pm,now,
(We) .,me m sme. indemnify., d keep bmrdcss,he City of Cowman again,
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liabilities, judgments, costs and expenses which may in any way areme against said
City in consequence sthe granting of this peanut,
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON - POINT
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Issded,by:
SOURCI3 REGULATIONS.
Date
Sigrw.am of ApplicamiCommnm Date
Re -roofs ..
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant., name buildiagsenp :am il,mo, handle henad.nsnaarOaI"
Type of Roof
"dclinrd by the Cnpn I'll,, Mun....al Code, Chalpwr 9.12, and Ill, Health and SaRly
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Coda Senior 255320117
❑re% ONO
All roofs shall be inspected prior to any roofing material being installed. -
Willtheapplicamorfuture building Occupant use equipment Or devices which
haxardnus
If a roof is installed without first obtainin g p on, g an inspection, 1 agree to remove
emit air sundial units as defined by the Hay Area A it Ouahi ly M magemenl
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all new materials -for inspection. Applicant
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understands and will comply with
all non -point source regulations.
I have mad the hamrduus materials requirements under Chapter 6.95 of the
Cli ifontia Health & Safety Cock, Sections 255115, 25533 and 25531 1 understood that
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If NO building doesn.tcarmly have a tenant, 111,11 it I% lily msp.nsibiliry to comfy ale
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Occupant Of the mquimm.nts which must be me( is or u, issuance of a Cl,adieate of
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Occupancy. -
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Signature of Applicant - Date
. All roof coverings to be_ Class .`.`B•' or better '
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Do...Oranth.lisedOscar Dam
OFFICE