01060017 CITY OF CUPERTINO " - -
Btnt.Dwc DIVISION PERMIT CON.TRACTOR"'iiwoRMATIo .
BUILDINGADDRESS: PERMIT NO.
OWNER'S NAME:
APPLICATION SUB DATE
PHONE:
SAN ARYN CONTROLNO.
ZO ARCHITECr/ENGINEER: - BUILDING PERMIT INTO
w
Z W BLDG ELECT PLUMB h1ECH
�<a U C"U 1' C__I
S vOmi= LICENSED CONTRACTOR'S DECLARATION Job Description
ZO Z n e I hereby effrm that 1 am licensed under provisions Of Chapter 9(commencing _._
F=h; with Section]00U)of Division l of the Business and ROfessions Code,and my license
dzwais is full force and effect.
Date
u.
e=.a REPLACE 50 GALLON WATER HEATER.
w 3 tar,U Date CommDECAI
a O�' ARCHITECI"S DECLARATION
f
„5 I understand my plans shall be used to public record
.6 o O Lsenxd Professmnal -
�_ - OWNER-BUILDER DECLARATION
I hereby aPoim dust 1 am exempt from the CmaismiC,License Law for the _
F'Z< following reason.(Section 7031.5.Business and Professions Cade:Any city or county
Acwhich requires a permit to construct,alter.improve,demolish,or repair any structure - f - -
i 3� Pno..isusu ce,also requ nes toe appl cmi far such pcmuuo f l stg°ed oommem
0.1 he is,I ce sed pursuant 10 the prmv di f'he Cunvawh Licera,Law(Chapter 9(commencing ithsmton7UW)ofCivilian3 rmaBus ss ndPOfessrmsCode) I"; y ) -.] ,S,q FtrtFloorAre�_,. , xx Yl uation
."hot
s exempt Mertfmm and Ne basis far the alleged ldiempn6d.Any vims on - -FSS
4 °•' _. . .1 s. J, 8 tl•7
of Section 7031.5 by any appFcum for a Permit subjects the applicant to a civil penalty rA�shU{��i I
of notmore that five hundred dollars(SSW). . 369L /V NrSmge� ' Occupancy Type
01.m owner of the property,or my employees with wages as their sole compensation, l U4�j
will do the work,and me snocium is nor imended or-offered far 1.11(See:7(kl
Business etd Professions Coda The Contrmtor's License law does riot apply m m s !>,j: C:;7 c
Owner of property Who builds or improves thereon,and who does such work himself 502 - F I NAL PLV 1vfY5�.�N V 'CI1V 1':IC�Y
r through his own employees.provided thin such innitursamem,-1 not intended or
Offered for sales If however the Wilding o mp emear Id -iNn-once year of - 506 GAS TEST
;..
improve N,do,Ownerrbuilder will ha meb burden mfprovingmm headmr wild or 507 — FINAL PLUMBING
improve T Purpose of build) t ''
Ohas owner Of Ne ro' _. . ....: . . . _. .....-. ..... ..._. ......... _ ..__ _. _..�_,1
P perry,am Business a convening with Lcenud convenors m
construct the project(Sec Ito an Business and Profess ons Cale)The improves
Contractor's
and h Law does not apply m an owner of Property who build Or improves t 1.the
andhecs License Lo such projects with a convvctor(sl,licenud pursuant so rhe. -. .. _.__,.__ .... _-L _
-
Contractors License law. _..__-____.._..___.___._.._._. -...____
❑lam exempt under Sec' _I B&PCfar this;season I; 1.4,_. t��•,; _, .
Owner
Date
.. WORKER'S COMPENSATION DECLARATION
- Ihereby affirm under ycnaltysifperjayOneOftsmfollowing declarmions F=11yALer
❑ 1 have and will 'maintain a Caufical,a Camara ib self-hasuse for Worku's
Compensation, " provided for by Section 37W of the Libor Code, for the JULO
pe"Ona.me of the work for which this pcmut is issued., JU 20,01
❑1 here and will mair air Worker's Compensation loa,"ria,as required by Senian
37M of Ne Labor Cod for the perfo ce of th work for which this P< "t is
. Issued.My W kers Compensation Ins a cam .and Policy number,am:
UILDIN(a.
carrier. L t, JPolcy No, i 6 I, r '.4., I p t
'CERtIWCATIONOF,EXEMPT10hY FROM WORKERS ..�_..". ltY__-. ..k t-1 lk�:�1: ', .I ILJ
COMPENSATION INSURANCE'."�•";°';�',,:...
" s section need nm be cdmple4d if the peruser is for Or¢huidrcd dollars " -1 I :
(SIW)eror lelcss.) I
1' ri fy that the p rformanc of th rte far whish this peim is issued,1
hall not employ any person in any manner so a to become subject i°the Workers IZ"' •1 "1't'� I t ! •-"'
C.Opensalian Laws of Califomiu.Date
. APPliemt ... �,., ..a.__e..., )
NOTICE TOAPPLICANT:IL C¢rmaking tionthis Cenins- Exemption,you should '- "
Z becoone with comm with
ssisiom Compensation provisions of the Lobar Cale.you must `
z p f nh lM1 comply sv!h h p Ovisions o this permit shall b deemed revoked. i
:r .. G ....... .. ....._ -. _. . .. ..1....
CONSTRUCTION
LENDING AGENCY j f q: M1 - I'
1 he by hi but them!s s co t-Sec. lending-g ncy for the Performance ? r t
AL1; of the work for which this perms is issued(Ser.1097.Civ.C.) ++ _ I '
p" z 'l enders Name ..._.. -._. _...... . .. .... . ... - .-.. _I_.—_........._.__._.._.-_.____. __. _.__ .. _
�.•-� LcmaeraAddresa
U I-'
I certify tom 1 have read ails city
anation and arum that the°hove information is
'�., toWilding
I con to comply with all city and county ordinances and site laws relating
>. 'he aildie-nonswedp andherebyfar noperIriae ro am,mivcs of thincity to enter upon
Y I¢7 the aba(We)lime
i e to prapen i inspe d tee purposes..
es.judgrceio save:andepensesk hihurmlesg the Cnyofemengainst old
City in co judgments.costs and expenses which msy;ln any way accme against said
V Z Ory in consequence of the granting ofthis
etrti
APPLICANT TANDSAND WILL COMPLY i W-1'TF"
ALL NON POIYf
SOURCE REGULATIONS. Issued by: Dale
sigoodua°fdppliaanJConeweor !.. Date':, v
:HAZARDOUS MATERIALS DISCLOSURE"'; - Re-roofs _
.:
Will me apptinn!n 1 rebuild g acuPmt nate Or handl ba..' terwl "Type of-Roof
a,a - — '
he
CmI.Section f
ired
ion 2531( rind hlu cpalC de Ch pt r9 dih He. ands rely = a ; ),` i`, ly• ) L`-'>i_ It 'r ! r Il',:1 .
Code 9 i n.2553 f ) f f
�Y`" "° ,i �' A1Lroofs.shall,be.inspected.prior to any.rooftng.material being.installed. ._-._.
Will the upplinnt Ot fumu builJing ocapam use equipmem or dcviao-whi<o If a roof is iiistalled Wiihout first obtaining alt inspection `Pagieedo remove
e t
District?
us av contain nanis as def d b th Bey Art A Q al"iY b(lig mens
D ro=t .. r, P g wtll,coTnply wi(h: ..
all new.matertals for-inspection—Appllca'nt understands and
"'t '7"°' all non-point source re ulatlomlt,T.
I h a read th hu d s mat n l,ocircour.,um,j Chapter 6.95 of the °
cafifornits Health&Safety Code.Sections 25505.25533 and]553a I ndeotad that
Rthcbwlding Eos nm cumnily hmeS mnmi;chat ii is my rcspbnslbliiryio notify the -- - - ----
weupam of Ne requirements which must be act price,to iswance ofa Certificate of '
ampan=, Signature of Applicant _ . _..._. Date.. ...
Owner orsatharaea agent- ' " Dole All roof coverings to be Class B" or better '
•
OFFICE