02070115 CITY OF CUPERTINO '-
BUILDING DIVISION PERMIT .CONTRACTOR INFORMATION:
BUILDINGADDRESS: .
18771 ARATA WAY WATER HEATERS ONLY PERMITN 82070115
oWAI�N"gbNG 970 E. MAIN ST, SUITE 200. APPLICATl054Sl l Ea 7/-72002 PHONE. (415) 566-2209 SANITARYUNO, CONTROL N0.
i
0O Oz ARCNITER/ENGINRiER: BUILDING PERMIT INFO
z to 0 BLDG ELECT PLUMB MECH
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y i LICENSED CONTRACTOR'S DECLARATION REPLACE WATER I-)' :ATE
lhertbyoffof mmin 3 of
dunderpmil Nor..i Chain,,W..fommccense 1pLlOn
;rn t-u
with Section]0001 of DivisionJofine Business and Rofnsions Cale.and Cry license
is
in,
rorcc an Rr3
O W U License CI J Lic.x 7 S 7
3 a N Dam O C.of, r
ARCHITECI"S DECLARA N
O 1 understand my plans shall be axil as public records
i
ip o Licensed Professional
m OWNER-BUILDER DECLARATION
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1 hereby.(five on 1 o empd from the Convenors License Lou,far he
h z a allowwhich ire reason.(Section]o I.S.Business and Professions h.or Any city orCountymoure $700
E€o which requires it a permit m etmswa.Wmr,improve.demolish,or repair any vmnurc
sPlmt ha is licinsedfurswmso the cions ofdM Con ttm'inofil<esigned statement.
_ _., -. -,requires the applicam for such
- p.. prmm tmculs and Professions
r law ons C n 9 3 9 FP Q'H6r.*6h-N
(commencing wide stniarr6cri and
tDivision 3 Olds!9usid c.end im.Any vi Cade) i fV' {{ r,� 4 s 3 m z - Valuation
or that he is Exempt theiefrom and the basis for the alleged cxcmptibri.Any violation � � -
-oP3ecdon]0313 by arty aPPlieam for a permit mbjeas the applicam m a civil penaldy-
fofnmmmemahfivehundrzadollars(s500). 5021PNIaUN&L PLUMB ecupancyType
❑Lea owner onhe property.err my employers vertu wages as meh sole compensatloa, 506 - GAS TEST
will-do'me work:"and the structure is'not imena2d'of offered far sale(See:70a4 50 _
(Busineia arid Professions Calc:The Conmemr's License Law dos not apply to an p'ectioiis" ' ` ••t
Owner of property Who builds or improves thereon,and xho does such work himself
or through his own employees,provided that such improvements arc not intended or
_Or
forsale.if.hove a me Wilding Or improvement is acid withinamyear or. _... __ _.._. . ... . .. ......... ..._-_
mampleuon mowner-Wilder owner- ld ill have the burden f growing that he did not build or ^' '•.t. :.'i ':c-
prove for purpose of sale.).
❑1:as awnspr the popery am a.sines y contracting 'm Code:)
contractors to
scantrain the dims
no(Sec ]to a,Bounces d Profs Code.)The improves
themon. a CY
License law does nm apply a an j owner of P pent h builds se puna ce hereon Rsm
., ond.wctor's wets Law.
a w.ch.pro)ecu with conwmorts)licensed purwant.do me.
01sax La . - AUG U g
onwaol License }
❑lame pt oder Sec :: t ';H&PCTs1.this mason 2002 . ^�•il .'.
Dom .
WORKER'S COMPENSATION DECLARATION - BL.11LDIIdI�
1 hertby eRrn under pemlty of perjury one ofthe following dedaratiom:
j ❑ 1 have and will'mointim'e'Cinif2ae'Of Consent at self-mCion for Winkvs
Compensation,-as provided for by Secdon-3700 or the Labor Code. for the
performance of the work for which his permit is issued.
�have am will maintei i WOCxr's Coiupemudum insomn6e,as mquirtd by S L ion
of the lobo Code for he,Performance of thework forwhich thispcmut s
cd M V!o Vs Com e s d�n Insurance o' end P licy nu be '
Cem CPolicYN JS'
CERTIFICATION OF EXEMPTION FROM WORKERSo
- - s. .,.. ,eli v, '•.f,'.i •� . IC:i
�, t -QOMPENSATION INSURANCE." s
_
'(Thsttuon n'ced not he dompleied if the Perms s Forane hundred dollarss.. ,, (,,-"�1 1)- -----
($100)or less) -
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y performs c bf the s t for me ws ct 'tut Workers l
Cum nil mplay wy person m any manner so s m become subject m me Workers' f ( - `- s .,16,.", '
d .
compcnsauon Laws of Celifomia:Date` 't- "• `" -^ s
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NOTICE TOA to the NT R'after making th s Certificate f E Labor
on Code. hould ,qg. .
forith t 63mno the such sCompe t pe. t nail dhc erne mvoyou maid
� 0 fonM1 m ropy with such Provisions or thisperms shall b<tl ed revoked.
't I r° !"1CONSTRVCf10N LENDING AGENCY in ':r �f; "'
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” 1 hertby aRmi dun mere s e conxdrbcdlon Irnd ng'agehcy fo the performance
�.q ars rot ork for Mento pennu a¢sueE(sea 309] C .c.) ., .
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r1Z
1 n fy th d 1 M1avc W th ppi wt t a t that dh ebo o f ritition's
fzt,F+ amen 1 8 e d comply th it sty ontl c iy o dmances d sum laws mgs
�.(� do build ng mnawceob.and hertby eumoriu rzprtxnkdiv<s of roti cirymcnmrkiupon
� W the above rnent oned poperty f nspect an p ryoxs
((��'Gr• (W)egrtt ie.save mdemh fy and keep hamdeas the City of Capers'o apnnst
h"W liabil t cs Judgme ts,coca and spans s,wh ch may e y w y ecc a agemst said
C) z City do co saga ce of me gdenwB of h rm d - � �
APPLICAN'TII\T)ERS .,'s 1 RLL OMPLYN ALL\0\ Ii. 't• /
souRCE REcuLArroNSfs � � e Issued by: Date
Signature df Appl:cmnA;z t6r' ";' .,.. Dme'F[.., /
Or
RIALS DISCLOSURRe
E " -IOOf$
`11f WR the appiidahta fint building ow p in if. 6,handl harardaaa'matedal .....Type.Of ROOF . .._AAAA_ _AAAA......_
as deli ed by the Cupertino Municipal Code CI.pt 912 and the Healm nil Saf ry
Code Sen on 23332(x) s y i rM1,i •'k..u, r t
Oyes tl t kt } 1 • . i 1 _
All roofs shall be inspected prior to any roofing.material being installed...-_.....
All ms air c ic.m o f t e W in a:c p d u a if r devices which If a roof is installed without first obtaining an inspection';d'agree:taiemove
`oil heard arm ant as deft d by m Hey q if Qu I ty Men g me t
" all new materials for inspection. Applicant understands and will comply with
v oy r r aa�. . . .. P
all non-point source regulations t -
1
District'
ve sad,me',hexvdo s amnali raga rcmenu under Ch like 695 of rthe
i'
Cal romia Health&Safety Code Sdcd ons 25505; un
25533 and 25534.1 dersand duet
fm<buildcurrently
gdoes not h am eanmthaPt`cry spq sbl'ryt imify.Ne
uccupi d of NG 9ui which must W mel to issuance of ate o
Cenifef
Occup nn "
T A Date
_ ,_Signature of Applicant _
"7-1 �f Owneaam :dnt . . -._._.. .___.
E Dad All roof coverings to be Class "B" or beiter
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