01060062 CITY OF CUPERTINO
BUILDING DIVISION- PERMIT CONTRACTOR INFORMATION:
S BUILDING ADDRESS: PERMIT NO,
1054 COLONY HILLS LA HOT WATER INC 01060062
OWNER'SNAME: _ APPLICATION SUB DATE
JOHNSON ALAN K AND BETTY J 2531 GRACELAND AVE 06/12/2001
'PHONE: SANITARY NO. CONTROL NO.
- 1 650) 298-8494 .
G z z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
E00 .
pF BLDG ELECT PLUMB MECH
N¢4 GJ IU l_I L._I
Z 8 yZK ,LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm licenced
that I am under provisions of Chapter 9(commencing
�mFuOi with Section 7000Rof Division 3of,haBusinesxand Profissions Code,and my license
is in full force and effect.
��< ueen emaa ue.x REPLACE WATER HEATER.
3 LL y
Data Cmumctor
ARCHITECT'S DECLARATION
N a 0< I understand my plans shall be used as public records
ad 6 0 Licensed Professional '
pcOWNER-BUILDER DECLARATION
X i hereby affirm that I am exempt from the Contramor's License Law Rolfe
I-Z a following reason.(Section]1)31.5,Business and Professions Code:Any city or county "' ••'
Ftowhich requiras a perruirt conduct,alter improve.demolish,or rep Y structure
d 3. -pli.1 t t Iapplicant
q ue th ppl a t f by a rile b tl t t r
'I'loboCCAPht tll'.nLpo.sr _ Inc t L Loss(Chase,9 S Ft IoorArefi , ` _. $5YOuation
( tang with Section 7000)of Division 3 or do Basta and Pmfgsson.Codi
or that he is elempi theafmm and the basis for the alleged exemption.Any violation
-of Section 7031.5 by any applicant for a permit subjectathe applicant.a civil Mail,
of hot oma than five hundred dollars($500). 3591%M�19m*p i ..,,,.>; Occupancy Type
01,as owner of the property,or my employees with wages as thei r sole compensation,
will-do-the work,and the structure isnot Intended or oFftrcd for sale(Sec:7044;"
'Business and Professions Code:The Contractor's License Law does not apply to an 502 - FINAL PLM191VUs
u�
' o fp ,arty Who builds p than and he due,such workhimself
or through his ply provided that such improvements am not intended or 50,6 . 7GAS_.TEST. '
,off ed par suliti if,however,the le g carie "u 'awithin b myear
bl f 507 FINAL PLUMBING
completion, hhId 'llhtheb burd❑ fp gth th dd
t P e f p rp e f Ia.).j
❑I as ow project
p pry I ly m cnng with ll n ec k tra t t - s 1
Owner for such ro ec c n Code)The C nt t r
and h contract owner f property who l u Ids mproes thereon,
L L d is w th r tor(s).licensed p rsuam to the
/3 J
construct p J t
not PP'Yt PPY
P 1
Contractors Ccense Law.
❑I mPt derSc " - 'B&PCT this ••' 1 L::L�I,
D r
WORKER S COMPENSATION DECLARATION
t Ihereby affirm under penalty,°Epe1rY one of the following declarations:
El have'and'wi11 mi'a'Cerdhcate of Consent Yo'self-insure for Worker's
Compensation: as,-provided for bySecond3700 of the Labor Care, for the
_ performance of the work for which this permit is issued
01 h sera land oil)mairminWorker',Compensation 1 su as required by Seel.; _
37M of the from Code,,for the paiformari the work for whichthis permit is
;ss C k My WofsC pe sa 't IdP I ynumba I r am
C..er t.t PI'c No
CERTIFICATION OF EXEMPTION FROM WOR KBRS j
COMPENSATIONINSURANCE "" .._._.... .-.___.:-. _._.... .. _. _
s (This action reed not be completed tF the perms is Por one hundad dollars -- +'" " {'`'" j s
(5100)or lcse.) - '
his Permit is
nfY That in thson nanorice' frthe
so as to bedmor e sub ed to Ne r l
shell n t to
Y.a^Y P Y ma _ Je^, Workers '
Co.pc i Laws f C Iraq_
Date "
..AP9hcam
:NOTICE TO APPLICANT.It Fl k' gdr,C,rd mof Exeaunion-youshould
z ^ f iro eh of object mply whenW kir C-',pen t p _tinof,h Lim Code Y mostRoduva
s
z p tarss
Q amh ons thisall be deareed revoked,
«•s).rA ' �' ' t CONSTRUCTION LENDINGAGENCY
I hereby affirm th I there .a co m i ]coding ag y f theperfo n ce
as r�i of the wok for which this permit siss issued .3097,Cis.C)
Led""Name'__, -o :r ._..... -._. .. .. ,_ ... .-.. .. __ .
Led Address', -
V � I caiofy that i h e read this appl cation and state than'he above information is
W [r c t.1 agree to comply withall cey and a(untyunfirances and state laws relating
to building construction.andlbandbyauthorzeP representatives ofthis cityro enter upon
>I the bo - i red .,ody f mspe t o rP -;es,jgeeis d id keephatheCdCupertino against
tn liabilities,Judgments,costs and expenses which may in nnywayaecrue
against said
APPLIV:❑ CtynCcAoNnEUNDcBRfSNTWe,IDS AND WILL
p COMPLY-
WITH ALL NON-'POINT
SOURCEftEGULATIONS
Issuedby: Date
S gwt fApplicanVCnnuhnor :: : -'- .,Dote' Re-roofs'
1❑ HAZARDOUSMATERIALS DISCLOSURE
PCupertino 2, handle n Nen material TYPe of Roof . ,_. . ......-_.
a
Code Seaton 255420 12 d the Health and Safety
�.. .. . . .. .-'t r ..�.
licaut
Yea ❑NAll roofs shall be inspected prior.to-any roofing mang teal,bein installed
defined by UMu orFormbuilding¢'Pal Code.arrogant Chapter 9 t ` - -
I Will the applicant g
future rebuildioccupantuseequipmentordeviceswhich If a roof is installed without first obtaining an inspectidn I'agreefo'reinove
emit hazardous air contaminants as defined by the Bay Area A Q ality Management ,
Disttat P materials for inspection. Applicant under and will comply with
all new mat
❑Y is >, ❑n - all non- oint source regulations: ,_ - -- -
1 havercad the hazardous mate al equvemems under Chapter 6.95 of the
California 3understand that
ra Heahh&SafeiY Cod S t n 25505 25533 d 25534 _... .... ... .... .. _.. -. . . ...,-.... ... .. .. .._. .... -..
IftM1 bldingdoe._ C dyb- ' t lth`tt 'Y
O cupani of the re,. , ems wh'ch most be memprimr to a e of 5 Cenifi me of '
O P Y . .
- .. .._ _':. 1_... .Signature ofApplicant .. -._. ._..... _. Date .
Owner ov"if.aniseed age nt, Date All roof coverings to be Class,`B"or better ;
7i