99120109 CITY OF CUPERTINO � °*'""� '`-�"G' • '"�
BUILDING DlwsloN PERNIIT COIVTRA ®�I1�Fk�Q., ATrOT
M UU !"' LIUME
BUILDING ADDRESS: PERMIT NO.
WATER HEATERS ONLY 99120109
OWNER'S NAME: TT-RQ20N REP PERMIT ISSUE DATE
NE: SANITARY OLNO.
ARCHI'IECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
• 0 0 0 0
upijJob Description
LICENSED CONTRACTOR'S DECLARATION
N
1 hereby tramsat 1 sen licensed under provisions of Chapter 9(commencing
with Section 7")of Division 3 of the Bualncased Fmfcuim s Code,and mylimmadis nmTf«<eandefrect. WATER HEATERS
License Class LN.N
L Dau COmbrcbc
ARCHITECTS DECLARATION
1 undcocand my plans"I be court as public mmrds
Licensed propos n ani
OWNER.BUILDER DECLARATION EXPIRED
f I hereby anion that 1 am exempt fsom the COnuanOYs License Lew for the
i O o followingrattan.(Section 7031.5,Business and Profensiuns Cade:Any city Or county
Z$ff which motions a permit to mnmrut slur,hnprow,demolish,or repair any structure
F Zsn prior m its issuance,alto requires motPPRant forsoch permit in file a signed treatment
F C that heI.licensed punuantto the Provision ofthe Conuumr'slheum Law(Chapter 9 Sq.Ft.Floor Area Valuation
as (eanme«ing wiN Smion 70007 of Divuim7of the Busimsatnd Po(euions Code)w
.. that me exempt tMmfrom and the basis for the alleged eaampden.My Ard.tfeo Of
Section 7031.5 by any applicant for a permit objects the applicant m.civil Penally of 3 M1N"M0er 0 0 Occupancy Type
no mom dun five hundred dollars($500). .
❑1,as;Owner of the property,m my employees with wages a dmbulecompensadon,
will do lhework,and thesbumum it melmounded woffned forsale(Sm.70/4,Bu
udneRequired Inspections
and pmR Rmx Cast:The COnuattale s I-mb.Law door apply m an maw or q P
propmr wbo I W l a«imProwa themon..nd wbo toes auN work hivueu w Nroagn nice
Owneer,mea,provided Innvemimprowmmta.mne year fcmpletonfwsalelr-
nmaewANemiltingarimprovementishaltwithinut yearwwmpkuortheowner-
bolldtt will have Ne burden of proving Net he did Out ddld m improve for purpoha of
tiled.
❑1,as matter,of dm property,am=elusively contracting with licenced eonlacmm m
conduct the t e project(Sec.7094,Business and Professions Cade:)That Consomme,LI-
censc law does not apply In,an owner of Prap oly who builds or improves mcmar.And.
who cenuams for such pmjecu vim a conusaor(s)limned pint m the Conuatoes
License law.
❑l.m namn"under see ,B k P C for this reahan ,
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby taus under pmralty of pttjoey aro of dim following declamations:
1 have and will maintain aCoHiau of Contrera or oulf-tnsum f«W~sComport-
tion,as provided for by Section 37M of Inc labor Code,for the Perimmuse Of the
work for which this permit Is issued.
❑1 have and will maintain Worker's Compensation Insurance,an required by Section
3700 of the Labor Code,for the per(wmanec of the what f«which one permit is Issued.
My Worker's Compensation Insurance carrier and Policy number am:
Canter. Policy No.:
CERTIFICATE OF IDDIMPfION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectim need nothecomptetedmane permit m foranc hundred lollem,41 )
or mss.)
1 certify Ina,in me performance or the work for which this permit Is issued.I(hall not
employ any person In any sanncr an u le became object m one Workcm'Compeaadon
Laws of Califomla.Dam
Applicant
NOTICE To APPLICANT.If,aMr making this Conifiam of Exemption,you should
become subject m me Worker's Compensation provisions of On Labor Code,you mum
Z fonhwidi comply with such provision w this permit shall bo decom!revoked. '
LZi O CONSTRUCTION LENDING AGENCY
[—i I hereby asnrm that them It a cementation landing agency for me per(armams of
!Yi the work for which this parent Is issued(Sha.3097.Civ.C.)
Lendcfs Name
7 Z L msesAdd.
U Q I cenify that I have read this application and Nm that the above information is
uy F coney l agree m comply with all city ad county on inamxa and sale laws misting to
O V building conetmetion,and hereby omadm rep¢ha nsfim of this city m m ct upon the
lid above-mentioned property for iupcNon purposes.
(WO).gree m ave.indemnify and keep holes;the City of Cupertino agsfnt
Vin c«uequa«e of the ranting of this permit.
V7 Ii.bilities,jedgmenu,costs end expenses which may in any way semen against said City
7 g -
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signaure of Applic.ndComtsucmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant w fretum building mcupnt come,w ltaedk haudoa material
as denmd by du Cupertino Municipal Code.Chapter 9.11.and!the Health and Safety
Illi` Code.sectio.26532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONO
Will the applicant or future building Occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haakoa air conuminanu a defined by dec Bay Area Air Quality Management all new materials for inspection.
`� itlriett '
❑Yes ON.
Hon
mW me haaWo=mamriam moms room,under Chapmr 6.95 of the Califor.
nit HcolmhSafety Cole,Scedon25505,29533and25534.Iundcmtand OuifmO building
deet nowunemly how a mmm.Net it is my responsibility m wary me axupant of the
mgviremmts whim mutt be met prat m outcome Of a Cenlacam Of QaPucy. Signature of Applicant Date
Ow«r Or aumariued gent Date All roof coverings to be Class"B"or better