02080137 CITY
ISND
DIVISION PERMIT CONTRACTOR NORMATION:
BUILDING ADDRESS: PERMIT NO.
22907 CRICKET HILL RD WATER HEATERS ONLY 02080137
OWNB6S E: APPLICATION SUB DATE
viMDEGTYAR 970 E . MAIN ST, SUITE 200 08/23/2002
PHONE: SANITARY NO. CONTROL NO,
(415) 566-2209
Mai ARCHITECf/ENGINEER: BUILDWG PERMIT INFO
m C BLDG ELECT PLUMB MECH
I I I C..J
FF LICENSED CONTRACTOR'S DECLARATION
0 O v=Ni 1 hereby (firm Nat I sm liecnsed underprovisionsof chat 9(commencingJob Description
°„-,°„ with Section 7o")ofDivision 3anheBusin«aPfssionscde.and myuansREPLACE WATER HEATER
<yf< ismfuur.r`ea" 5-7
z z z a License C b Lic.p
°'0 n O Daterunor -
LL LLO ri, ARCHITECT'S Coo "nal Al10N
S I understand my plans shall be used as public records
'nos
pO Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt form the Contractor's License Law for the
c- a following reason.(Section 7031.5,Business and Professions Code:Any city or county $700
E F O
whichrectumsa permit to construct, lu pry d wm
demolish,or repair any scm
coreLprit issuance,nce,alrequiresthapplicantf permit pert to file asgned statementis.
NathesIm5edVatmt to 66 pmvsuonsfdid Contract rsLcense Law(Cnapter9 .A I• a Valuation
aammeMnng with Section'r")of Division 3.f Ne Business and Professans coded ltd , 34�13P30��.56 „1,1 - = 1rj
or that he is exempt Neifrom'and the basis for the alleged exemption.Any violation t f,.t s„ _ s,i.f .7,
-of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty CCn
rarnot mom than avehundred doll.(s5om. S02APNtOTI*rL PLUMBIN ENERGYQPand Y Type
°I,as owner of the property.or my employees wiN wages as their sole compensation, S06 GAS TEST
will de Ne' Pro and Nc'saircrode: o C ntract is Lie a Lawered for sale(Sec,'to an 507 - FINAL PLRB4Br Nflspeetions”
Business and Professions Code:Thn is.1 rot's License Law does not apply 0 .
.wnc
r of property Who builds or Improves thereon,and who does such work himself
m through his own employees.providai Na such improvements are not Intek,or
;.Rete,Tor'sale:IC however,the building or improvement is sold within one year of
completion,the owner-builder will have the burden of proving that he did not build or -
improve for purpose of sale.).
❑I as owner of the P c.7exclusivelycontracting i N l sedcontractors to
construct -- - -- - -"
consthe prosect(SeIBusiness and Professions Im
s C )The cmr's
2. to a
License Law does not apply t f property py h builds Nercon tf tri ry A LyL '��'
_..and who contracts(ofsuch,prosats 0 . u.contracmr(sl I cense,pursuant m Ne .._ u�l�I 6�
01 m axe pt under
law, fsl-, l' -
- _ ❑lam exempt under Sec.' � ' ;B&PCfor this..on
Owro, Date SEP 0 4 2002
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of to following dechmaimma BUILDING
° 1 have'and will maintain a Ccraficam of Consent to .self-insure Iia Worker's
Compensation, m provided for by Section 37W of the labor Cade, for the
verfmmauscr of the work for which this permit is issued,
_ I have and will mainmin Workers Compenutinn Insurance,as«quirt,by Smian
- 37(1(1 of Nd L3Mr Code,for Ne perfpwance of Ne work for wM1mh Nis permit is
nsx d.My W srl crs C pe -f Insur aria and Policy number are
Came
af• ICERTIFICATION OF EXEMPTION FROM WORKERS' V 4✓'.h s 's esi lstV:` if;IV;.'.,3
COMPENSATION INSURANCE"-
' t'(This section need not be ample¢)if the pe"niI is for no hundred dollars - --------•. -( j': •1 .
I5100)or lass)
I ert fy that N pen manner
u to co h N. permit t s n serer l -
shall'or employ any Persian m any man s N nccome subsea to the Workers
pmpcnsntion laws or Caldomia.na
Am
Applicant ': .__. .
.tecorCETOAPciflic T.If aBcrmam gh st ilicaeof Lated,on.you should
d. o...a,
Z becomeh comply
Ne suchpr Cions or this prom tshaofthelabor Calc,you Nun '
O forthwith comply with such provisions or this permit shall be deemed revoked.
._. _.. .— ._.-
--_
F �'', CONSTRUCr10NLENDING AGENCY
E.
'mm"
affirm Na there is a conswmmn lending agency for she q:rfonndneceldniviodclia s I" •.
ti —find Name' N reis is
n sued(Sat 3119'/,Civ C)'
Lordcr',Addresshich' W
I c mfy sh t I have read dfix ppii.,i.n ad ,are Nat the how information is
IL;O F io b'IG'I greet i s. ad humb- mlimice omply with at I city and countychordinancesd state t Iowa misting
order
U 8 in u p scmeuves of Nis city to enter upon
>: pj ,the above mentioned propend for ifyandinspectionkeep
pmrsas.le
F. S (We)agree
me t,ave,cost and expenses
which
hamay in the of accrue
against
F. Vi liabilities,judgments,cans and expenses which may in any way necrve against said
U Z Ciry in consequence of the Framing of Nis Permit.,• v V
APPLICANT UNDERSTANDS AND COMPLY(W6JrH ALL NON 01Nppp Issued byi Date
SOURCE REGULATION r ;y� yQPZ
Signature of ApplmantlContmaor .�. f�� R.7� Re-roofs
' HAZARDOUS MATERIALS DISCLOSURE 1
whore applicant ame Type ofRooE_
app g pant stoic or handl harardo. matenal .. ._
Roof-
as defined by the Cupertino Municipal Code Chapter 9.12 d the Health add Safety
Cod Sect. 2553.(a) .t IC. Ir 11 l'J'' s1 rd. sS
°Ye �'� All roofs shall be inspected prior.to.any roofing material being installed.
WII the it heaat future huild'ng p t use ea p t dice: men' If a roof is installed without first obtaining an inspection; I agree to remove
crostM1 ill c conte tu ,definedby byte YAreai Quality esims m Dianal? all new materials for inspection. Applicant understands and will com I with
°Yea. Rte! P Pp .P_Y
all non point source regulations. : ..;,,.,.
1 have read the harardau,materials requirements under Chapter 695 of the
Califumia Health&Safety Cade.Sections 25505,25533 and 25530.1 undersmnd that
-if the building does not currently have a tenant.that it is my responsibility to nd,fy the
occupant of the requirements which must be met prior as issuance of a Certificate of
Occupant
Signature of Applicant ., _. _ Date
Owner or tahmimda m ,Data, All roof coverings to be Class "B"or better
d _ ..:___... ....__..-_
... OFFICE . -. .