01120074 BUILDINGDIVISION PERMIT CONTRACTOR 1NFORMAI'ION:
BUILDING ADDRESS: PERMIT NO.
11121 CHADWICK PL WATER HEATERS ONLY 01120074
OWNER'S NAME: APPLICATION SUB DATE
BRUSH CAROL A AND JAMES A 970 E . MAIN ST, SUITE 2( 012/19/2001
PHONE: SANITARY NO. CONTROL NO.
(415) 566-2209
o•RCHITECTISNGINEER: BUILDING PERMIT INTO
z C BLDG ELECT PLUMB MECH
Ni r 1-_1 1 `1 1 1
LICENSED CONeTRACTOR'S DECLARATION lob Description
Ihereby ethnnthio1 %3mfOc under provisionsofChapmr9(commencing
iinfation]000)ofDivisionJoftheBusinessanaProfeuionsCodc.andmyliccnu REPLACE 50 GALLON WATER HEATER
1...<
Y Y is in full frac and cc 7(l 7�
n c.u Licenu CI Lic,a
d. Doc S DECLARATION/
O ARCHITECT'S DECLARAT ON
,rt c I understand my plane shall be used az public records
iW
i d p O Licensed Professional
OWNER BUILDER DECLARATION
I hereby alTtm that 1 am exempt from the Contractor's License Law for the
f-z a following reason.(Section]031.5,Business and Professions Code:Any city or county C 700
E Z o which requires a permit to construct,alar,improve,demolish,or repair any structure MM
T prow to its issuance.also requires the applicant for such Permit flea signed suument - - - --- --- ------ - _
eat M16 enRrcuaed pursuant m the of Division
of the Contractors Beene law(chapter osCod 9
or Oat
he is ewiesntion]roand tebasinooteeleed ca.ander.M vi rod. 1".' i r,3 ,1t7�9°f? ;; '. �,l" Valuation
or a ci he;s exempt therefrom and the basis for the alleged camphor.ho Any violation
of Section]OJ GS by any applicant for a prnniuubjccu the applicant to a civil penalty
ofoat mote than ave hundred Lenin(SSW). SOPI4NPTMI, PLUMBI G ENERGgccupancy Type
❑1,as owtrtf critic pfopeny,or my employees with wages as their sole compensation,
wardo'the work,and Line structure isnot intended or O&md for sale(Sec.7616,
Business aM Professions Code:The Contractor's License Law does not apply to an 5 0 7 - FINAL P HI'1G63pections
owner of property Who builds or improves thereon,and who does such work himself
or through his own employeeprovided eat such improvements art not intended or _
offered for sale.If,however,the building or improvement is sold within one year of
completion,the owner-builder will have the burden of proving that he did not build or
improve for purpose of sale.).
O L ss owner of the property,tun Business a contracting with licensede Contracts m
mnswct the project(Sec.]6b t,Business and Professions ills or The Contractor's
ismil h law does not apply man owner of progeny who builds se improve thereon, r
Co who AlLicersel. such projects.with.a conveewrts)licensed pursumt m the ®...
Contractors License law.
❑1 am exempt under Sec. ,B&P C for this reason '
Owner Date JAN 0 8' 2002
WORKER'S COMPENSATION DECLARATION
1 hereby aRnn under penalty of perjury one of use following declantions: BUILDING
meI have and will maintain a Centficare of Consent to self-insure for Worker's
ompennBon, a provided for by Section 37W of the Labor Code, for the
per/ormvrtce of rhe work for which this pemtir is issued.
have and will maintain Worker's Compensation Insurance,a required by Section
J]00 of the Labor Code,for the performance of the work for which this permit is
issued.My Workers Compensation Insurance carrirer and Polity number am:
Cariier.' . .. .Policy No.:1. 5
.. .CERTIFICA ON OF EXEMPTION FROM WORKERS'.'
COMPENSATION INSURANCE' _
phis section need not be completed if the permit is for one hundred dollars '
(51W)or leas.) _
1 certify that in the performance of the work for which Nis permit is issued,1 .. -
shall not employ any person in any manner so as to become subject to she Worker'
Compensaion Laws of California.Date
Applicant - -
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Q 2 become subject to the Workers Com ednndon provisions of the Labor Code,you must
forthwith comply with such provisions or Ws permit shall he deemed revoked.
Z
CONSTRUCTION LENDING LENDING AGENCY -
GC > 1 hereby affirm Out erre is s coned(Sec. lending agrncy for the performance
W
of Lender's
work for which this permit is issued(Sec.J09],Civ.CJ
Q Lcnda's Name -
� Z Lender's Address; .
V O 1 cedify Jut 1 have read this application and state that the stator information is
cormi l agrtt to comply with all city and county ordinances and mu laws relating
�.V to building construction,and hereby authorize representatives of this city to enter upon
y W
she i bore-mentioned property for inspection purpoua
yCLI (we)agree to save,indemnify and keep harmless the City of Cupertino against
Vi liabilities,judgments,costs and cepenses which may in any way accrue against said
V Z City inconsequence of the granting of this
peach-APPLICANT UNTJERSTANT)5 0. CCOMPLY YITH ALL NO
SOURCE REGULATIONS. /Ol Issued by: 12 Date
Stgmsmne of ApphcanUConveaor Dare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Wdl the applicam or Powre building ncupenumrt or henNe hazvtlous mamr al Type of Roof
as defined by the Cupertino Municipal Code.Chapter 9.12.and Ne Health arM Safety
Cade,Section 25532(.? , / -
Dues 9N All roofs shall be inspected prior.to any roofing material being installed.
Willes Our contaminanm or ts
building by the occupant use equipment Minagemich
nt If a roof is installed without first obtaining an inspection, I agree to remove
emit h will d s av plica minanu m budding by the Bay Arra Air ent or Management g p gr
District? - all new materials for inspection. Applicant understands and will comply with
(• °Ya all non-point source regulations.
I have read the hazardous manns2 requirements under Chapter 6.95 ofdiCalifornia Health s Safety Code.Sections 25505,t it
and 25534,1 understand that
if the building does not m currently w have a must
lh tmet o is my nuance ofity m notify the
aCeam of the requirements which men be ren prior m Issuance of a Ce ificam of
per, Signature of Applicant Date
ownernr,athedaed gw / D,m All roof coverings to be Class "B" or better
OFFICE