0104005941
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS.
PERMIT NO.
1074.4 BROOKWELL DR
HOT WATER INC
01040059
OWNER'S NAME
APPLICATION SUB Dal fi
JOHNSON GILBERT AND CATHERINE
2531 GRACELAND AVE.04/12/P001
ONE.
SANITARY NO. CONTROL NO.
(650)298-8494
O nliClll'I'F,CI'/IiNGINIiIiR: -
BUILDING, PERMIT INFO
BLDO ELECT PLUMB MECH
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CI I� 1=1 I-1
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.lob Description
I hereby iffirmthnt l son lienttd under nowitarsof Chapter 9(commercing
ce with Section ](X101 of Di, Mort 3 at he Busloeasand Potassium, Code. today license
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Uimofull lasaande `ef
Liana Cclan I.IC.N
REPLACE WATER HEATER. _
Date Cont incmr
N ARCHI'IIiCT'S DECLARATION
I understand my phos shall be umd a, puhlic records
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ppp,
v
OWNLR-I11111.I11?R DECLARATION
heurebylly offir affirm 1 from the Cummcum's Liana law for the
on 1. , Inari Pndeadon.a Code: Any city o, musty
nfollowing renewed, (Section ]0.n 5,at, due,
_
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land
O improvu,h nreasiirmay
rcywrasfipcmsoir mavresthe
prig applicant Permah,
priorntslts iensdprmsquires theapplicantthe
Sq. Ft. Floor Area
Valuation
—
Cepermiuoliensaimed Cloolstatement
that beishigwithSrsuannoNeprovivisin3ofthervcmrsLicensvlasv(ChaWC)
Ic Ing with Section ]IIW) of Division 3 of the Business and Pro@Armani
that ne
or Seth hu ie Ianvirvm and the basc ration
alleged exemption. Any on
ofSec] 31.5 b d cube
l fen
applicant lin a permit subjects the applicanno a civil pcnulry
o than five
ar nm lnarc than Bve nnmered daBam ($sltm.
hu dred
APN Number
Occupancy Type
C1 I, as owner of the property, or my employees wit It wages as Iheiranle empensatin n,
7W-Rq GO
will do the work, and the scmre is not intended or offered for role (Sec 01114,'
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Required Inspections
Busincen and Professions Code: The CmarucmL.a Lorena Law does not apply ro an
net
x' r o1 properly Who) beikk or improves thereon, and who docs such work himself
'
or his own employee.. provided than mel itnprovemrma ate not intended or
502 — FINAL PLUMBING ENERGY
offered for sale. If, however, the building or improvement is sold within one year of
n,phron,theowner-hudderw,It tasemcbmderofprocingdue hedid notbuild or
506 — GAS TEST
impnwc lin putpaav .1 n:dc,).
507 — FINAL PLUMBING
❑I,asnxmet Ofdto proprol am cxrinaively mntrai with fianaed amorueter,
couslunicl the 1 / t (See. 7044 11 w. jund Prolos,,jons L(xI ) Fle, Cjeujaeca.s
License Law does not apply to an owner or property he builds or improves thereon,
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and who contractsfor such mai with a conamemar%) licensed pursuant to the
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Conn I 1
1
❑1exempt udorS ,li&PCfor this reason
O
Owner Data
WORKIiN'S COMI'ENSA'I'ION IliifLARAI'ION
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I hereby affirm under Penally of perjury one of the fallowing declaretiio
I 1 have and will maintain a Certifcam alContent to self -insure for Worker'•
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Canape nsatian, as .Invited for by Section 3]0() of the labor Cede. for the
,
perTrmance m the work for which this pcmtit i. issued.
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❑ 1 have and will maintain Worker's Compensation In.wimoe, as required by Seen..
37M of of the IaMn Code, fur he pnffmrtmanu of the work for which this permit no
mrd, My Worker's C tperesation Inafrunee carrier and Policy numbervw:
'
Carrier: Policy No.:
01 WFIFICATION Oh EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
,
(ilia action need not W completed Vilna permit is for rme hundred dollar
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Ib I0(b or less.)
1 unify that in the pednrmanm of the work for which this pcmtit is issued. I
shall not employ any person in any manner m as to became subject to the W'orkero
Corownstnioo Laws of CoulLmla, Lac
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Applicant
NOTICE TO APPLICANT: if. ai making this Cenificatc of Exemption. r. h..Id
become subjat In the Workces Compensation provisions of dm Labor Code, you must
lorhwi'h comply with each pnrvlxion. cr thin permil .hall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby nffimvhm'here is o eonenuvtian lending agency for dm lmrfomnmee
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ufthe work for which this permil is I .... d (Sac. 3097, Civ. C.)
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l horadds Name
Lender's Address
,
1 amity that 1 have read this application and state that the above information is
om
cmon. 1 Ogren ,, comply with all city and county ordinances and state laws relating
to handing cmtslmalian. and hereby authorize amrwalarvcs of this Ci'y nt enter upon
the absue-reend red pmpuny for inspection purpasc.
(We) agree rot save, indemnify and keep harmless the Cis of CuMaino against
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liabilities, judgmems, coats and espvnsea which may in any way reerue agfoo, said
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City n cmdcynenee flh. gramm.g be, prmsLIC
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
Issued by:
Date
Signature of APpdcanUGmlmcun Date
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the aphrand (it ludium building occupant same or heirodie hartardotio material
Type Roof
yp oo
o defined by the Cuperlino Municipal Code. Chnpmr 9.12, and the health and Safely
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Code.Sec'iom 255320)Y -
❑Ycs 0 N
All roofs shall be inspected prior to any roofing material being installed.
Will thea,dicaut er future building nccupamuse equipment ordevices Much
emit haeardnus air coal mninner, as defined by the Bay Area Air Quality Management
If it root Is Installed without first obtaining an inspection, I agree [o remove
u' I3 g
°
'i'minI 1cn °N" -
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
I have read the mous mmeriak under 6.95 of the
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California Doubt et 505.2 533a 4.1Chapter
33 and 25534. i ",incur d thio
Safety Cade, Smdans 2551thin
I li
Iflbe building dues
s brave moa, or
itis my....ncnibiht sooty the
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incen w n
cupanl of the rcyuiremene which mus tic and prior m isemnro of a Cenificale of
and Con
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Occupancy.
Signature of Applicant Date
All -roof coverings to.be Class "B" or better.
Inner or rallumned age lnt Dam -
OFFICE