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CITY OF CUPER'1'INO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION -r,
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BUILDING ADDRESS:
WATER HEATERS ONLY
PERMrr NO.
18784 ARATA WAY
03010033
OWNER'S NAME:
970 E. MAIN ST, SUITE 200
APPLICATION SUB DATE
DENIS SCHNEIDER
01/07/2003
I40NE:
(415)566-2209
SANITARY NO. CONTROL NO.
ARCHITECTMNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
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with Section 70(I(1) of Division 3 of the Business and P ..fitmimn Code, and my license is
L¢oslomeClaand` ` -b Lica 5
fConuacmr
REPLACE WATER HEATER .
F=INALE®
Dale
ARCHITECTS DECLAR TIO
I understand my plans shall be used as public reco ds
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt foam the Contractor's License Law for the
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following reason. (Section 7131.5, Business and Podlessions Code: Any city or county
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which requires a permit to concoct, alma ucture
improve, demolish, or repair any str
prior to its issuance, also requires the applicant for such permit to rile a signed statement
Sq. Ft. Floor Area
that he is licensed pursuant m the provisions of the Contractor's License Low (Chapter 9
$990tion
(commencing with section T"d of Division 3 of the Business and professions Code) Or
that he is exempt them(,.. and Ne basis for the elcged exemption. My violation Of
beP Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
D I, u owner ofthe property. or my employees with wages as dui, tele Compensation,
will do the work, and the svucwm isnot intended oroffered for.mle (Sec. 7614. Business
5e2 FINAh Gy
uire n specuons
and Professions Code: The Conlrectafs License Law does not apply to an owner of
5 0 6 - GAS TE
properly who builds orimproves thereon, end who doessuch work himself orthrough his
owncmployxs, provided that such improvements are not intended or offered forsale. If.
507 — FINAL PLUMBING
however, the Wilding or improvement is mid within one year of completion, Ne owner-
bell@r will have the Widen of proving that he did nm build or improve for Purpose of
sal'.).
❑ 1, as owner of the property, am exclusively canuacting with licensed can.,. m
concoct the Project (Sec. 7004. Business and Professions Code:) The Contractors Li.
cove law dose not apply to an owner of property who builds or improves thereon, and
who contracts for such pmje,m with a contncmr(s) licensed pursuant in for, Contnnor's
License Law.
❑ I and, exempt under Sec. . B At P C for this moven
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby afmn under penalty of perjury ane of the following declarations:
1 have and will maintain a Cedifieau of Consent in uIf.in,.m for Worker's Compen-
sation, as provided for by Section 37M of the labor Cade, for the performance of the
it for which this Permit is issued.
have and will maintain Workers Compensation Insurance, axrequired by Section
700 of the labor Cade, for the pe formantt of the work for which this North is issued.
My Worker mpengs�ton unmx artier and PC ay man ran:
Cerner: MAl Policy No.:LGS!f2 j�t� —L)
CERTIFICATEOF KEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W complexed ditto permit is faronc hundred dollars (5110)
or It..)
I Codify that in the performmue of the .,it for which this permit is issued. I shall not
employ any person in any manner so in to become subject to the Workers Compensation
Laws of Cali(omia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
Wcome subject to the Worker's Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a Construction lending agency for the Performance of
the work for which this permit is issued (See. 3KN7, Co. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
comet. 1 agree to comply with all city and county Ordinances and sum laws relating to
building concoction, and hereby authoria representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree tit ease, indemnify and keep ha didess the City of Cupertino against
7
liabilities,judgmenu, onus and expenses which may in anyway accme against mid City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDSC PLY WITH ALy NO POINT
Issued by: Date I
/I
SOURCE REGULATIONS f/
Re-roofs
Roof
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Signammof ApplicanUConuacmrDate
HAZARDOU MATERIALS DISCLOSURE
Type of
Will the applicant or future building oee.p.m at.. nr handle haallous means)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code. Section 25532(.)+ rte,
E]Ycs
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment adevices which
mit hasafdaus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
Dyes E
I have mad the hanodous materials requirements under Chapter d 95 of the Cali for
nia Health A, Safety Cure, Sections 25505, 25533 and 25534.1 understand than if the building
does not cumerallitvu a mount, that it is my responsibility to noddy the occupant of the
requirements hoe tbemctpnor issuanccof.CenifcumnfQcuwcy
Signature of Applicant Date
/
All roof coverings to be Class "B" or better
Owner or authorised gem a