03020015 CITY OF CUPER•I'INO r 4, E' '
BUILDING DIVISION PERMIT CONITRACTORIINFORMA`TIONt
BUILDING ADDRESS: HOT WATER INC PERMITNO.
21053 CHRISTEN
_ OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
KAREN DAMP 02/06/2003
IONS: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECtENGINEER: B ILDING PERMIT INFO
I.ECT PLUMB MECH
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�00 LICENSED CONTRACTOR'S DECLARATION J DO ri Ion l
U 1 herehy effort That I em licensed under provisions of Chapter 9(commencing
With Session 90 ))of Division Sof Ne Business and Profession,Code,stet my licensees
murolowaw L_ REP EA E
•O�Z L, ce Cl Lk.N `
?N- Date ECTS Dcue 1+ _
r- ARCHITECTS OECLA ON
j o3T, I understand my plans shall M used as public records
•OyU
Licensed Professional -+
3 OWNER-BUILDER DECLARATION
y I I hereby affirm that I em exempt from the Contowim's License Law for the
s 0O following Mason,(Section 703 L5,Business and Professions GNB:Any city or county
a'c$2s which requires a permit to construct,alter.improve,demolish,or repair any structure
is prior to its issuance,also requires she applicant for such Noun to rile aligned statement
�sZs< that he is licensed Moral 1.Ne provisions of IM Central License Law(Cbapcer9 Sq.Ft.Floor Area $i$.jy0tion
FO (commencing tui to Section 7(ka))of Division 3 of the Business and Professions Cum)to
$
marine u exempt therefrom and Ne basis for J¢alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicator o a civil penalty of Zd$RUNser Occupancy Type
not more than five hundred dollars($50).
I,as owner of the property.or my employees with wages 0 their sole compevuion,
will do she work,and the akuclure is not intended orolfered forsale(Sec.7044,Business - FINAn
.it Prefeadmis Code:The Coe=Wes License Law does am apply to an owner of 506 - GAS TE Ire n eCIon
RGY
property who builds or improves thereon,and whodoessuch work himself or through his
own employees,provided that such improvements am not intended or offered forssle.If. 507 — FINAL PLUMBING
however the building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving Nat he did not Mild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed connection to
consfuCt IM prof(Sec.7044.Business and Prafessimts Cuxhl The Contractor's Li.
scrum law does not apply to an owner of property who Milds or improves thereon,and.
who cmntnces for such rejects with a centracmr(s)licensed pmsumt1.the Confol
License Law.
❑1 am exempt under Sec. .B&P C for this reason
Owner Dace
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury,one of the following declensions:
1 have end will maintain a Certificace of Consent self-insure for Worker's Camper.
737M
ion,u provided for by Section 3701 of the Labor Code,for the performance of she
rk for tubus 's pcsmit is issued.
ave and will maintain Worker's Compensation Insomnia,as required by Section
of the labor Code,for the performance of the work for which Nis Permit is issued.
Weikeri Co Missouri Insist ccaarrier and Policy numberrare:ricr. - .fk �Poliry No.:
CE TIFIC TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the permit is forme hundred dollars($10 0)
or Ices.)
I certify Net in she performance of she work for which this Permit is issued.I shall not
employ any person in any manner so as m become subject to the Wo lmoc Compensation
Laws of Cali forma,Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Lahr Code,you must
OO forthwith comply with such provisions or this permit shall M Jecmed revoked.
z .~N.r CONSTRUCTION LENDING AGENCY
[r l hereby a0lrm that there is a construction lending agency fonts Performance of
Iy' > the Work for which this permit is issued(Sm.3097,Civ.C.)
W Lenders Name
Z:) z Leadcr's Address
U 1 century Nat 1 have read this application and soon,that the above information is
W F+
correct.l agree to comply with all city unit county ordinances and sum laws relating us
QU building construction,and hereby sorrelmmosemmives of this city to enter upon she
W abnvcmentiuned properly for inspection purposes.
(We)agree to save,indemnify and keep harmleas the City of Cupertino against
TCA liabilities.judgments,Busts and expenses which may in any way acme against said City
U 4 in consequence of the granting of this Permit. y �_ _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date C's -
SO EREGULATIONS.� p
LN � //��,� -� Re-roofs
Sr nature of�plice aster am
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupants store or handle hansdous matenal
as defined by IM Cupertino Municipal Code.Chapter 9.I2,and she Health and Safety
Coda Schon 35537(.)'7 J All roofs shall be inspected prior to any roofing material being installed.
❑Yes 1/o No
Will @c applicant f/uture building occupant use equipment mrdevices which If a roof is installed without first obtaining an inspection,I agree to remove
is hazardous air onmmmanL, defined by she Bay Area Air Quality Management all new materials for inspection.
sole[!
Cl y.
No
Ihave i&Sanmad Nahanrctions 25505,2553 Rod 255341 t Cernmod bt ifthe hoCables.
g
his Health&Safety Critic,Sections 850als requirements
8s under hapten .95 if free burbling /
does not currently have a tens.Nat it is my Responsibility I.nnufy t cupmt of Ne
rcq�/encs whichmust he ahaccMr, �°� m 3 Signature of Applicant D e
G 7/r..�mnri'a agent / All roof coverings to be Class "B"or better