01020100 CITY"OF CUPERTINO
BUILDING DIVISION - PERMIT' - CONTRACTOR INFORMATION: '!I -
. .. ` PERMI'I'NO.
BUILDING ADDRESS: '
'
OWNER'S NAME: ^ , r�'" , APPLICATION SUB ON!I."
J
�.� PHONE' - I I o j + - SANITARY NO. f CONTROL NO. -
WZ ARCHITECT/ENGINEER: s ! ' ', BUILDING PERMIT INFO
O O 1{ BLDG ELECT PLUMB _ MECH
< LICLNSI 6 CONI I O
ACTPoS DECLARATION
z h& + 706 Description
OZ—O Ithereby fl th I I I d I fChrt 9( nmr mg
path Section7004)iifD A mfilhe R II f, Cd dJmyl' n
i
d� nlf
au Counia"orRAP
GALLON WATER' HEATER ,
W5u. ARCHIIECI's DLCIARAd ION -
��O� I understand my plans:h11b d iri public N: OCT .. -
pCLicensedP fissional- - 2 CT. .QR'U 2 01
OWNER BUILDER DECLARATION
m1 bercby offinan II a I 1 pl loon,me Coul,aclor,Lncrdsa Law lar the
F+ Y county -.e
toll mb ca (S t l 70l S Business m,I Professions Cod Any r my
k 0 ,n h 4 P 1 t 'I 6 1 J r_h P Y structure
33kk 4a .trio NoI. y d ispF tl 1 p L I g J: tcment.
that licinsed purtuart l e p is f theCoutractors L L (Ch,m0ode) Sq. Pt. F OOr Are -sValUitdOfl
(cu sang with Secton70W)ofDivisioneao the aced Wion.A9 as Cale)
rt
that Section
it exec I any applicant
li and the bper it subo alleged exemption.Any p s P v
y of ma mn 90315 by hu dred nni morn permit snbjeb¢the uppliemv rn o etvibpenully - -
atTal marem,mn anus hundred aaurn.IsSpo). ,. , APN Number r -Occupancy pe
El 1. flhl-IdY Y Ply ,,It al a,ll sl on In, - � .
arm .
3--
will the ndPmfeaand t."C,wtstructure na,earl` mrvLesmeoff
uwde or vote
pplym�o Mq dlnspections . ..
r of prapeny Who builds or improves Ihemm
am,and who does such work htsclf
or ihrnugh In—,n employees,pmuNed that such improvements are out intended or '
offered far sale.IL however.the haimmg or impmvemem iE sold wnhin our year of 502.. -.. FINAL PLUMBING ENERGY
completion,oneawner-builder will babe the burden of proving that he did not build or
impm emrpamas ar-.ale.), 506' - GAS TEST '
ol;asawne;athe pmpertYttme, w,Nero;mmmeangwith lieenseilcontractors to — 507 — ,.FINAL PLUMBING
Lal-Mout the anjeed(Sec 7044,Bd,incsx,ad Pop..lova Code',)The Con...curz s
icense Law that nm apply loan owner or property who builds or Improves Ihereau, -and who contracts for such projects with a mntmmor(v) Iicensed,purst l loathe .Ye
Gmtmnad.Licer sse Lw, : s -
Cl 1 am exempt under Sec ,B @ 1'C for this reason '
Owner Data - - -
WORKER'SCOMPENSATIONDECLARATION
I hereby Idfimm under proulty of perjury one oh'the following declarations: -
❑ I haSa and will-mainl,�in.ii Ccnidcatc of Con,onl m self-insum fur Worker's
@nnponsalion, as provided for by'Section 3700 of the Labor Code, for the
k;. prodamancc.1 the work fur which IN,perm',,is issued.
have and J 'lltandam.W A com,caspoi Insurance,its requiredhy Suction -
3700 ofahe Ltho-Care,for the performance of the'aod for which this gamit'e
ail.My Worker:v Compensation Insurance carrier and Policy nnmher re:
Carer Policy No ' - n
CERTIFICATION OF EXEMPTION FROM WORKERS'- ..
COMPENSATION INSURANCE •" - ! -
".(This action need snot he completed it the permit is forone hundred dollars
-($100)or less.) -
1 sunny Thal any
n in any maof Ibe work for wldaM1 subject
permit a im„uee,I
•shall not employ nny person in any mmvmr so us In M1ecame xuhjeet to the Wnrkcrs' '
Compensation haws cl'C,,lilornla.DataApplica
NONCnt _
'NO fICR'bject a he
I, olea,aCond,rakinglhis v,si nfil Exemption,you am,l -
ould
bee s,fl,c ject to the Worker's Coions or ti is pate stuns or the Lubar Code,coyou mull
Q 0 fonhwimh comply with such provisions or this permit nhull he decmetl revoked. 4
r . . -
H - CONSTRUCTION LENDING AGENCY
I h r by allim,that thera is a,oa,umhaa aIcm7tg,,gen y I' Ih da
pc ...a tee N oft) kf for lh prnl'I's'suul(See 309'1,Ci,C) n "
W Q
Larder s Name
U Lender s Addrc..
, - - t y - •I
I verfily that I have oddd'. ppli,r,ta.mat(hill h hn [ druid I a is -
ks [.., uatn l I agreeI -ply a] ,It ly J t} N I (t i g
O;V mh 'IJ g' ndua J hereby at lhorve repn-`Pnl,,i ves flh sett¢metier pan - ' ,• f .
�,• r� theb t Ipptvf 1 i rpm -
- 7py (W)ogre m a nJ molly"ord kraphanalect,flhe City fC p nim agairm
7Ln 9mi I f . 1 dy tie Is p h' may t way ay ac ue agn'nst sand
) City'in corisequence ofthe granting of th s permi a
APPLICANT UNDERSTANDS ANDWILL COMPLY WITH ALL NON-POINTIssued b '
SOURCE REGULATIONS. ' Date
y
, r
Signature of npplicanticonlrecmr' •a;Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE * - h-
Willthedppful fI M'II' goccuandstemorhmalleavrd aerial- aType ofRoof.
us del tied by the Cupertino Municipal Lode Chapter 9.12,and the Health anal Safety - 's
Ca de,Seatian 25532(x)?
[I yr, '. - 11 No All roofs shallbe inspected prior m any rooting material being.installed.
"
Will d - Ppm m none n m' e 1' I ='e9�p t d -' .,which •;If a roof,is installed without first obtaining an inspection, I agree to remove
emit b"-yid a am "msae defined by the Bay Ara,Air Qmally Manage nen
Di,16,11 ' 'all new materials for inspection. Applicant understands and will comply with
v °ves °"°` 'L all non-point source regulations.,
I'havc read the hueallous ralwaials rxdrin:mems under Chapter 6,95ofthe - d
C,,Ilfnmi,,Hulth,FSafdyCoJn,Sections25505,25533anJ25534.1 undctsmnethal
if the building docs net currently have a Imam,that it is my responsibility vrstadfy the - -
occupant or the_adedirenments which must he met prior to issional of it Certificate of C
Occupancy., ., - - a
SignaturepfApplicantpDate
All roof s to ba Class "B" or better
owner 11,amhorixm,,gem ' ., Mme f coverin- _ g '
OFFICE