03030072 CITY OF CUPERTINO r �
BUILDING DIVISION PERMIT bI -R .C'�OMFO , ANON•
BUILDING ADDRESS: - PERMIT NO.
JOCOBS ROBERT S AND DORIS C
OWNER'S NAME: PERMITRD �'U
&J - SANITARY N L NO.
ARCHITP.CLYENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION - Job DesCrlintOn\
1 hereby rein.Nn 1 am licensed under prenda s or Chapter 9(Cammencing
wllh Section 70M)of Divlsssn 3 of dao Burl.and protections Code,and my license is.
In full form and erect.
qq LImow Clect Uc.d REPLACE WATER HEATER f� (�
Dam ARCHf1ECT'SDECLARATION SEP' 6 5 2003
1 understand my plans&tall be used As public mmunh,
LicensedPrefcatland BUILDING
OWNER-BUILDER DECLARATION
a2 1 hereby affirm that 1 em exempt from the Contractors License Law for the -
ao following mm.(S
on. mdon 70315,Busimas and Professions Cade:Any city or county
a E which foquires a permit W construct.eller.Improve,demolM.or¢pair MY structure
Sw prim W its hemsoo.also requires theappliant fmsech permit to file a signed sacromt - ,
';Fpct duct be it Ransod pumo,W the pWNsions of the Contractor's Uanse LAW lost Sq.Ft.Floor Area - YEItlallon
D (commencing with Secllan]BOB)of Division 3 of the Busiwsand Profcasom Code)af _ .
that he it exempt therefrom and the bats for We alleged exemption.ABY viWadan of
Section 7031.5 by am/applicant for a permit sublecls the applicant W•civil penalty of .,A,PLT,ld,941r 0 0 Occupancy Type
notmom than Ove hundred dollen(S300). .7Y 6`L TVA
❑I,u owner of the property,m my employ=with wages as their sets compensation,
will do tie work and the me=bort bounded ox offered for ask Sce.7044,Business 502 — F INAL RFIfuIilMi14&dEHiERGY
and Pmrctd m Code:The Countesses License Law does sot apply to an Owner of
property who buildserr improcs dacrom,and who does such work himself&,through his 506 — GAS TEST
own employees.provided that such improvements am not Intended or offered for tale.It. SO7 — FINAL PLUMBING
however,the building or Improvement b sold within one year of completion.the owner-
' builder will lave the burden of proving that he did not build or Improve for purpose of
Able.).
d 1,a owner of the property am ealudwly contracting with licensed conoacWn to
wmnuet use project(Ser.70a,Rol.and Profession Code:)The Cn xuanoes Li-
serum .
law does not apply to an owner of property who build&or improve daemon,ad.
who contracts for such projects And,a cennactmb)licensed pursuant W tic Conomob
License law.
❑I sin exempt under Sec, B a P cle,this reason
ta
WORKEF MPENSATION DEC ON -
IhembyalBmlun Mtyofperjuryomofthefollowingdalandla OV -
hewandMilmainWnaCe nice ofCOnunttowlf-imumfmWofkee'sCampen-
sadan,as pmvldcd for by Section 37M of the Labor Code,for the performance of aha - -
we&for which this permit Is lam& -
❑1 haw and will maintain Wokefs Compensation Insurance,As required by Section '
37M of the Labor Cade.for the performance of the work for which this permit Is Issued. -
My Wa&ee,Compensation Insurance carder and Polity number am: -
Cartier: Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rh ts sad m bond not be completed If tin]um It Is forane hundred doll ars(SIM)
or less.)
1 arify dart in the performance of the work few which this permit is based.)shall not -
employ any person In any manner an As W became subject to ft Wmken'Cmnpcmnlon -
Laws of California.Dass
Applicant
NOTICE TO APPLICANT:If.after making this Ccniflam of Exemption,you should -
become subject W the Wofker'a Compensation provisions of the Labor Code,you most
O forthwith comply with
C mIpermit shall
revoked.CONSch TRUcIONLENDING
EGAOENCY
C4 l herebychi Wer dmrcbaconstruct.
icndngaemy for the perform...of
the work for which Nle penult is laved(Se.3W7,
Civ.CJ
(7 Lender's Nemo -
D z Landees Address
J Q 1 certify that 1 have and this applindon and stare data the show InfafmNon b
y ' eafma I agree W comply with All City and county odinaaa and silo law,mating W
'rU^ building contraction,and hereby mhodse representatives or this city W enmr upon We
117 above-mentioned property for impecdon purposes.
(We-)agree to an,Indemnify and keep harmleu the City of Cupertino against '"'
yliabilities,judgments,Calls and expense&which may in any way boouc aSaInAnd City L/.�.
L)7 In camrgnac of the grenting of this pc.IL
f.r AP LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
CE REGULATIONS
_ Re-roofs
ignstum of AppliesnVC n D -
HA DOUSMATERIALSDISCLOSURE Type of Roof
Will thcappllant futumbulldingor'cupanutarearhndlehuadouimakdeI
As denned by Om Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
ode,section 15531([)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
It haaNnus.1,contaminant,As dented by the Bay Area Air Quality Management all new materials for inspection. -
soim1
❑YCa jtrJ,Nu
I haw mad the huadous matedalt mgdmments under Chapter 6.95 of the Cali for-
rah Health&S.ImYCode.Sanmu15505,2SS33 uW255M.I under mW dm ifde Wilding
does too currently Mve a mount,thin it b my responsibility ut notify tie su to of the
remenls wMcb must"t prior Issuance ore CCNOcamofOccu Signature of Applicant Date
owbor a,anlnndveA, W All roof coverings to be Class"B"or better'