00100071 CITY OF'CUPERTINO - .'- e, r. _. ' -
w1LDINc DIVISION 'PERMIT, : CONTRACTOR INFORMATION:
BUILDING ADORE 0075'.APFI_E TREE' LR HOT WATERrIRIC PFR 1T N0' 001:000
HOT
OWNER'S NAME ' / APPLICAT .S
IONU IFtD9l
MICHAEL LIN 2531 GRACELAND'. AVE �ftP, tc000'
ONE: i 1 - ,r.'(650)298-8494 SANITARY NO CONTROL NO.
i , c... �' •
ea O ARCHITECT/ENGINEER - 'al t BUILDING PERMIT INFO
wm EE
BLDO IELECT PLUAIH'" MFCH
h6i
.LICENSED CONTRACTOR S DECLARATION - -Job;Description
- A
ZZ4E In by ff that licensed J I fChpl 9m
Comv cog P .,
r a� ims 7070) fl ro 3.f the BrIf r:, c 1 Al.,and effect. Tmy ,
l . REPLACE WATER .HEATER -
,a¢ Elc in failcross
ui3LLNDat cmt y, - '• 1
ARCHI'I hcirs DECLARATION -
'�&.�� . 1 d .t d y11 kllb d . Pnl'ctt J. td,' - • . •' . .
OLactated Ple..'r Wil
%n OWNER BUILDER Earn
the RATION
al 1 arr aff ih t 1 t 1 the d I's L L 1 the
H Z 6 `loll mg r a t (Section 70315,BusinessI I f n Code:Any city or arrivere - r,
pg F O wh h qu res pe mut t 1 p h p J I h repo anY s u ch n
6 3 w pr o f t - I y t o ppl'c t l h p n 1 1 g L t t n mn � v
Thain dp : tt J positions fn c t t I .(co-ptr9 Sq. Ft. Floor Area Valuati(ft
do g 'InSection man f Develop f theB . I Profession,Coulp `.x.71710,,'
or-tl al hes empt ihererm t anti Jte M1v !lodthn ulleyed a opt era A t1
violation'
of Sceu°n 7031 5byrayappmmt for u p nt bl c¢the app.' t t a civil penalty
of nod nme m„bvehundred d n at,PS50o) - - ' 7 APN L��L ,,nn��.GC., Occuparicy,Type
3�F,ae089.,�0 '.
❑lar 'milurtphe mormoner, intended
or Offered
for side(Sensri
wild 0 k Ito t t 'e tint Jd If reAf al (S
r'
Bt and Profession,Core:The Contra C ' Lwd rppry1.a t, Fowrm property Who I :ne nan d I weak 502 RP�1rE�4
ffi-
i ENERGY
through n s employees.provided dasuch p t tended or 11'AS TEST
eld'f 1 I[ thebuilding improvement is_ Id within ono year of �q6 -
,
ctmpli nth-owner-hudder willhave the landlanden ofproving(hill h Id net bold or " S�� "FINRL 'PLUMBING
improve frpupuseol al ). ,
°I a,owner of theproperty,amexclusively contracting g with licensed t emrsta s •. (- t
colinarea the project(Sec 9044Business d Promiskag Critic)TI C t mter'r ' 'x is -
1 d : t apply I n owner of prosody who bt IJ p partner,
and h contract,f h p 1 t, with da cit m)I t c cJ p of t
ad
Cothe- "
0 1 am esdarT,undcrSc. 13&PCf ihiri : -
O'ne, Dei
WORKERS COMPENSATION DECLARATION -
ax
Ib by oil I p 'Ip fpaJ rY ftl ill 6d I I
1 Ia td will accurate a Clearance of C n end tu celf-in-. for Wt des-r
'+ pun. f : provided t r byisoclinal-3900 f theLaws, Code, for the ' -
perl' mane the workf I' h(his Permit is staled, - -
°Ib e add will annual Worker',C ifen...... Insurance,as ar,madbyS tat
370 of the Labor Cadejor Cadthe lueformance of tlic,,osg for Which the p .m t is - •' - -
issued.My WnndsConapens°doer Insurance carrier anti Policy number are. -
d
Carrier Put try TIO� - c -
YERTII4CAnONOFF.XEMP'f10NFROM WORKERS' t _ • '
COMPENSATION INSURANCE.
(This section!ed itot he completed if the Permit is for handed dolltlrr, - -
I51OF)(Intel,) q t _ ,
l t
I certify that he the paroull of the work to,w1'1 tl ,rcrolit I,'sed 1
scull not employ my p y' n'In become subject t°the Workers
Compensation Laws of California,Datenn _ +
NOTICE TO APPLICANT 11',afmco
r okig this nCrounnueof Exemptioit,you should ' s' �,.• ' -
became subject 'he Workers Compensation pru" n.ofthe tah Code,you .t'
z0 z -Poon ith dro..ply uh rch p ''.tons° ths pvorut shall be ddhc,.kdd. - l
F ZCONST RUCTION(ENDING AGENCY - - r
1 hereby•B'mi that here ka,magraction Linduagageneyfinr the pvarfairmance v
Wof the kr which In,pe tt et.aed Nva3a)9,Liv.L)
A
local sh ne
tom. z Leal Address c•- 1 r
U this°
co1' 1tapplistatcation
-net th ! information s
I g cetocomp15 hIII city;,Old tyoditmJ tot Ill., I fog
U rob ildn6 .tf dhehyarh rp ti a
Ithvcity menter-upon - . .
'y r4 the mosor-romfirredproperty f '' .pet P p
(W)agree to save,indemnify andkeep h IsstheCity ofCaperino against
V] lablY: judgments,cooI expenses Which may in any way aceme.gnt.t ited
City regnence(if the granfng elms perm., - • r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT IaSnedb D3Le4'
SOURCE REGULATIONS,' Y•
Si,namha-of AppllumlCmhmctmr a.. ,. - F Date - Re-roofs
HAZARDOUS MATERIALS DISCLOSURE'
, Will the-applicant or firthe builifirpoccularat sureorfirndlctr : da ucterad 'Type•ofRoof
a,defined b1 the Cipertan,M (pal Cade Chapter 9.12'a I N°Heath and Safety '
Code'Section 25532(x) '-- - - • .. s �'. •^ "? s
°Y" "
El No All roofs shall be Inspected prior to any roofing'matl ial being installed
Will the split'cout orfut am baking occupant no,carpenter or devices which If a roof is installed without first obtaining an•inspection, I agree to remove `
enitl hazardous air enol nn.nfe coder ted by the Bey ArcnAir Uuaidy Moongemev
Di;iHcB all new'rnaterials for inspection. Applicant understands and'will'comply with.
Dyes ❑NO' " �•- all non-point'souree regulatirdri : .r
I.hme a ad theintention, t I: I Hens a tiler Ohoptcr 6.95 �f the. •l,, .• -�
Cn1'f a H Path&Safety Code;Sections 25505 25533 and 25534 I d and that
Iftl holding J t tlyla annual,ilrt it my re.p n.b'I'dyt n tlry the' e - ; ' r
tcc l to f.th regi irchu t which nmst be me(prier to issuance of a Certificate dl 's „ '
oc p x Signature of Applicant Date' ,
1
owner er aame .ea agent - - Date -,All roof coverings to be Class`B" orbetter
,, . t.
"