01090107�.. ;, _...
CITY OF CUPERTINO
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` CONTRACTOR INFORMATION:`"
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10285 COLBY AV
WATER HEATERS ONLY
01090107
OWNER'S NAME:
APPLICATION SUB DATE
JOHNSON RICHARD H AND MARTHA
H 970 E. MAIN ST, SUITE 20)09/24/2001
PHONE:
(415)566-2209
SANITARY NO, CONTROL NO.
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ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm that I am licensed anderprovisions f Chat 9 (commencing
wim section nivieion 3 orme Business dna Pmreaafona code. dna my Rcenu
REPLACE 40G GAS WATER HEATER
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e and eof
in fan mase dna rcem.
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License nse Class is
3 KKK V
Contractor
.Dd[e Contractor
ARCHITECT'S DECLARATION
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I understand my plans shall be used as public records
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Licensed Professional
OWNER-BUILDERm mE
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the
I hereby affirm ConvocOmr's License Law for the
following mason. (Section 7031.5, Business and Professions Code. Any city or county
$700
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which requires a permit to construct, alter improve demolish or repair any structure
ca
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'i..t `i, i3,1S9.L7V Lt7+I.�W aI\' �, t' �X'
1 Valuation
that hel is litairsed pukadam to thk ponivisms of the Contractor License Law (Chapter 9
(commencing nwnh thr TIDO)ofhe bsis3of the B,wiplla and Professions Code)
or that is exempt rhemfrom'and the basis for the efemption. Any violation
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im cre drd
of gecsion ]03 t5 by any applicant fore pvmit subjats the applicant a a civil penally
mfnmmamthan fivenunareaao1lars($500),
502`PN qTftt PLUMBIN
'
ENERGYOccupancy Type
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13 1, as owner of the property, or my employees with wages as their sole compensation,
506, - GAS TEST
-
will do the work, anal the muctuas is not intended or offered for sale (Sec. 7044,
'Business add'Professinns Code: The Contricar's License Law does not apply m an
507 - FINAL P]&di}SillMspesctions'
owner of property, Who builds or improves themon, and who does such work himself
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or to his own employees, provided that such improvements are not intended or
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�offaN for salt If, however the build ng am improvement i la within one year of"-
"completion;
the owne builder will have the burden of proving that he did not bold or
improve for purpose of sale.).
.. th tiu.s.e.d._ o t ac.t. o
CLa_ ns o f N. e_p . pe nY a exclusively o t fin
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mostrunt m (Sec 704 Business and P f ssins CoThe Giamatti
FINA ED
License Lawdoes not apply loan owner properly whobuildsor improves th n,
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entl,who contacts for such projects with a, commaII hcenudpursuam to the
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Connoisseursm,License Los.OCT
q 2 g00�1,
❑lam exempt under Sec' BAPCfor this reason
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'Gw'"Date .. '. '
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'�' WORKER'S COMPENSATION DECLARATION
BUILDING
hereby chart, under penalty of pc 1 ry , e m the following declarations: i
01 have and will maintain a ceitificaie of Consent to self -insure for Worker's
Compcnsmmi as provided for by Section 3700 of the Labor Cade, for the
perfo . of the work for which this permit is issued..
❑ 1 have andwill mainthoW.I Ciarpacructim firxrmnrespored by Section
3700 of the Labor Code, for rhe performance of the work for which this permit is
issued. My Worker's Cmi ... fiaofiramoome turner and PoTry bar re
Center : ,.'?til ;r. j, 'Epoll, No '."r,
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CERTIFICATION OF FROME WORICE,RIS
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COMPENSATION
OMPENETION INSURANCN
., ... COMPENSTION.WS��NCEt - ...
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seebon need r,ot be completed R the is for one hvrMmd dollar
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(x100) 1 ss..., ; :,
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1 carrify that in the performance of the work for which this permit is issued, I
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shall not employ any person in any mco
anner so as to beme subject to the Workers'(
Compensation Laws of Calf ia: Dine'
_-
Applicant....
. .
NOTICE TO APPLICANT If, after making Campion, Exemption, you should
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bac subject Ndreg hire 'Compensation - provisions onsonsof the0 Coda you must
of theft
foMwuh comply with h provisions 'ons o thispum c shall be deemeald revoked
¢me
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` ?iii CONSTRUCTION LENDING AGENCY
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1 here fi dot them construction ct n 1 ndm a en forth rf
bl',. B 6 cY performance
off
f the w k f h ch chi permq issued (5 3097, Civ. C i
li d Name -
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Ibnders Addeas .. ..
thi
-I1crt th t 1 have
'off'
hat b
n and stain on is
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/Co%n Gr
t g ceccomply withall city and county ordinancesd scam laws relating
to building nms, and hereby ausanae msentatrves of this racy to eine
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pan
the aovementioed property for inspection polous.
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,the
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s,y g to save: ankeephaChi fCupnino
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liabilities,judgments, t d expenses which mayinmy way e <magainst said
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APPLICANT RST DS AND WILL COMPLY
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WITH ALL NON -POINT
SOURCE REGULATIONS.
Issued by:Date
signet fApprcanUC nmaclor ..�. `.' •, . Oa¢ ,
MATERIALS DISCLOSURE
Re -roofs
HAZARDOUS
` Wi11 the opplitant or future b 'Ithng pant store or he m hazardou m also.]
Type of ROOF -
as do fjne4 by the Cupenino Man r p 1 Cod Chapter 9 12 and the Health d Safety
Code Section 25,53.21¢)
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..All roofs shall. be, Inspected piior to.any roofing.materlal.being installed.
theapplicant orfuare building occupant use equ p, t r devices which
foramina.
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If a roof is mitidled! Without first obtaining an inspectidri Fagree:td remove
em'Will
t air conte med b the Ba Area A Q m cy Management
y
Disco t n. ...,
r
all new materials for inspection. A heart 1
L' Yes_ ❑
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understands Wltll
p pp p y
all non=pomf source regulations. .and will tom
'No,
1 have read htiiardops Chapter bf
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u
the mat q is
orals re a remen a' 6.95 the
Cslifomia Heahh &Safety Cdde: Sections 25505; 25573 and 2553421 understand that
War,
:iftabu'Idi ill cunendy have. moral tht it a my respo'th fry i hanfy the
'occupc t of 'he requirememswhichdm be t p ilio iss id.Combou he of
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0` upramy
Signature of Applicant Date
All roof coverings to be Class `B" or better
own o ampn sag t r ;, i. Data
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OFFICE _..... .. ... ...._..
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