03030002CITY OF CUPERTINO
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BUILDING DIVISION PERMIT�L�rtjV'aty��1�
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BUILDINO ADDRESS:
WATER HEATERS ONLY
PERMIT NO.
21063 CHRISTENSEN DR
03030002
WNER'SNAME:
970 E. MAIN ST, SUITE 200
PERMIT ISSUE DATE
PEARLMAN DALE L AND DARA B
.
03/03/2003
NE:
(8078.357947
SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 o t� In
j LICENSEDCONTRd under SDECLARATION fChap
1 that 1 am IIcemM under provigons Of Chapter 9 (Commercial
Job De�c,�iption
rt wiu3a�mg10frect. gonJof NeBugneu and Pro(essiam Code. and mylicerlmk
im,70 1R .f
REPLACE WATER HEATER
? Llcmom Clan Lk.I
Oath canmerm
ARCHITECTS DECLARATION TION
MAR 2 5 2003
1 understand my perm Nail he used as public records
BUILDING
p ILDIItllB,
Licensed Professional
OWNER-BUILDER DECLARATION
q 1 aft that 1 Law for IM
form the Contractorsoe:
D fallowing moon. (Suction 1..tempt
Marto BugFunt and my c
oli Code: My cry m rounry
which requires a pmmh ac ennaweL almt improv), demolish.
construct. ova, de Fi repair any
Room
acquires preapplicant rot such permit toFileLow(gned tamment
t
pdwmhaiensedp 7000) the Contractor's Li Low
< that he(comm
Sq. F[. Floor Area
IOM '
pursuant
pursuant
nttoa previsions am.
mini with CMIC)
3 Coca) or
r
SCm1)som
77th BugnW Nd Proon. Any
B
of
.. met he u eumpt timnfrom and Om buts (or the alleged eumpRon. My violation of
"been mounpm and Ran bull th vi
[ Occupancy Type
SeNon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
MI mon dun five hundred dollars ($300}
0 1, u owner afore pnpeny, ormy employes with wages u deeirank compenudon,
willdo dmwork. and me sen t. it rml intended woRemd fw sak (Sm.70a5, Bualws
and Professions Cade: The Contractor's Lim.. Law dean not apply to an owner of
qujre nspecuons -
propertywhobuRdsmrimpowsmemon,andwhodoessuch wort 0imsel(orthesugh h4
ons mploywra
,providedRutsuchimpm uremsarenotmdedornaecdfwaale.It,
506 - GAS Tl
507 — FINAL PLUMBING
however, the building of improvement is said within am year of compledon, me aware.
builder MR haw the burden of paving that he did not build or improve for purpose of
tale.).
K1, as owner of the property eamceun am desively communing with licensed nvmle
amcl the project (Sea 7041,01, Business and Pretensions Cade:) Tee Con actors U.
come Law den not apply an an owner of property who boilds or Improve, dueraon, and
who contracts for such projects with a commctor(s) licensed pursuant in Ran Conractor's
License Law.
❑lam under Sec ,B&PCf this
'
Da¢s
WOO RKER'S COMPENSATION DECLAA RATION
1 hereby alarm under penalty of perjury aK of Ran following decimations:
IMw and will mainWnaCeNnum ofConunt mulRimun for warkelsCwnpen-
\
union, u provided for by Section 5700 of me Labor Cade, for me performance of Ran
•�
work for which this permit Is Issued.
❑ 1 have tad will maintain Workers Compensation Insurance, as required by Section
3700 of the labor Coda. for the pertofmmn of the work for which this permit Is Issued.
My Workers CompewRon kuraow artier and Policy number tae
-
cmim: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section Fund not he nom plemd R the perml0 is foram hundred dollars (S IM)
or lora.)
I coufy, that In the prfotmance of the work fes which this permit Is intend,) Nall not
employ any person in any manner an as in hecome subject to the Workcn' Compensation
lawn of Califaruia. Dal)
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Faempion, you should
became object to tha Workers Campwnion provisions of the Labor Cada you moat
forthwith comply with such Previsions or this permit shall be deemed mwked.
3CONSTRUCTION LENDING AGENCY
1 hereby affirm dui then era construction lending agency for the performance of
the work far which this permit is issend (Sec. 3097. Cl, C.)
jLenders Name
Lenders Address
I codify that 1 have mad this application aM mm that de above Infoonidon Is
corer, l a{Me m comply with all city and county ordinances and sum Ism Mining m
building comwction, and hereby authodre M NTIMMI IM of thlsaly to enter upon the'
a shove-nontioFud property for ImpeNon purposes.
1)
4 (We) agm: to save, indemnify tad keep harmless the City of Cup RM) against
�l
D liabilities judgments, costs and espensan which may In icy my scene a{amal said City
P In consequence of the {taming of this pormlt.
"
APP ANT UNDE DS AN ILL COMPLY WITH A L NO -POINT
Issued by: Date
S RC REG LA J` %`�
Re-roofs .
��`{, ofa_-3/3/D
IgnatammAppnantlComomor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will de applinator ftouM building aocupanl stop or handle hsurdow material
U defined by the Cupertino Municipal Code, Charter 9.13, and the Health and Safety
e, Oyu No 33575(.)7
❑ Yan i�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant er/future building occupant um equipment w devices which
I havadom air contaman
ints u atm d by the Bay Area Air Quality Management
all new materials for inspection.
Dlgrlet?
"
❑Yes TRV.
.
I have Mu the hauWwsmatodalsrequimmemsunderChapter6.95 aline Calvet.
ni.Unllh&Sal.1yCo@,Secdom25515,25533and25S3e.1un@tamdthmifth. building
tlFus utronl y haw s m t It" y tuponghillly u ncdfy the ocoup" [ft
nm nm wnlen m.e tpgar aancc ar. Ccunam rq_a)a cr.
Signature of Applicant Date
,4
All roof coverings to be Class "B" or better
Ownm
or authodvctl agent Dow