00080174 CITY OF CUPERTINO * :
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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CIWNER'S NA B -• ' t' �. 1'/ — APPLICATION.SI16 DA3E -
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O ARCHITECT/ENGINEER. -
IiLIIC `-BUILDING PERMIT INFO
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FCARATlIONL
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thatmIherebyafnel licensed arp fCnpte9n
ioz' ithS REPLACE ,WATERHEATEp R
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OWNER BUILDER DECLARATION l -
u� 11 ly ❑ tlrtlat plf theC t t L L (or tM1� ,
6 fall g (S t 7031.5,B : J P t :Code A y ty. ounty • - - ,
O wh hI Permit i .t I ❑ p J I'n p cy....car.
63? prt t < L 1 th ppin uulp n'u fl 'g J:rlcmcni
s I
Dan m : 1p : Imile p fm c .at. I e I (Cl tern - S . Ft. Floor Area Valuation ,
mmnc
(coeng is th Section 7000)of Divu.mns,
Division 3 of the Bus nsd Plaon.Coq. -
or that be is exempt Iherefmm had the basis for me alleged examption.Any violation' -
ofSectmr7fH15by,any applicant for ap t subjects the appy n civil Penalty
'orm nmore ma,Bee na,prau amwrx($500). - .APiq3fd ,Occupancy Type.
CI it,owner of thepropely n myempMy e ,in wages.sd 'r,oh uri ppmut t will do the work,and the t t I intended or offered f' (See.7044 f1� -
B fucks ad Pick.: n CJ 'Th Contractor's L La does lapply m,it 10EY SE�Ir ' ❑5 .
:F liproperty Wn n ld improves m and 1 i work himself nmo UNDe FLOG' F'L"UIIBING
or through his own employees provided mat such imp nvements,r.den mended or t— �; ..
opened. :Life If-n the building 6i improvementis: la within oneyear of —01 — ROUGH.. PLUMBING
c
nS pl t' thewiser b IJ E haw theburden f prat.,that he did not build 'A
lip f purpose al ale). ,.,. } - 30 , .— TUB .x <(-1R, SHOWER
•CLo.owner of the preperty,.,it axei..ivcl..ttntnteline with licensed eontrack,r.to 502-_— FINAL PLUMBING, ENERGY
.n. L the pN i Its 7034 B . 1 and P r Case, lila Counselor `^ GAS TEST - ,p
alae n 1 I c' I Puc t ' fp pep n Id p s thereof,
e h contracts r h oroicetx with a tmunrtx) a P I I I me .
Ell t . License L . ai 567 ' — FINAL. PLUMBIIVG
J ❑1 an,es,raft under Sia. N k I C fitr this reason'
Owner , '-Date
WORKER'S S COMPENSATION DECLARATION
ION
Ihereby anion underpenalty ofpjy 1 the Infusing decli' -
it '
C I have Laid ' t Ce o f to if 3Corson,I I[ f Worker', - !
Ctt p i provided t by Scott.. J700 f Ih L b f the + r
pert to l the vourkf h I this permit is cc.d. A
xh dwilli m ar ke :rk p i rkc In.t y abyS e
f n
7l fah Lima,Cnt f theI' f c Ise kr hhIlpermit
io
war7d.MyWarloarsCompeonsamuntinsurem r and Policy enumerate: (/ m,
Carr 1V1G1WCy.Dory- PEyN .NF �ORKE
CERTIFICATION OFFXFMI IION FROM WORKERS
COMPENSATION INSURANCE
.ubon nerA mt be completed flho permlf isforonehwWred dull : ` a '- `rM1� r -
1$I00)or lelcssJ, -
1 certifyman in the perionnathere)I flic.olial,for which this p min is"..ull •'n: + -v ,
Shull our couple,an,fiction in y manner so as to been rte subject to the Workers is.Ina
Compensation Laws of California,Date .
.'t', Applicant - - 4 r' ..
NOTICETOAPPIICANT If ftmakingth' Cen'I 't tfE If y should -
Z become bh Et theWorker's C p t p t theLabor Care,'y most d -
0' Q forthwith etamplywith such piovisionsorth pcilpitshallbedetailed m,oldd - - -
'.F'bti CONSTRUCTION LENDING AGENCY
I h by afi on Ih t th l t n le d ng ase y for lho perlormuncc
a of the work far which this peormt is'ssacd see,3097.On C) f- '
W'Q Lenders Nane '3 I't•
' Z Lender's Adds ^ l • .� '
Vt fY Ih t i
here read In,.,hu,anno f a sone that Eo,p fiflormarlion
FT+ [y wtt g t ply lh II 'ry J ry N m n e a h l l let ng
V nobb Id' g .true. I a Ih by 'not,
.pre. tY : fah'. ilY is enlvr upon - - r-
�, r� the aM1 rctf LPs, lyf ' .peel p p : .. +
Ey'0„t
(w);Rl sa and n'fy Ik ph' 'I.s the Cly fCpn' gins. -
Z liabilitiesi dg m. c t I p ch nay in an,w Yru aounne, old
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City-n cortohuence of th starting of th s ermu - 11 _ _ e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH`ALL•NONPOINT
• SOURCE REGULATIONS— /,a Issued by: -'��- Date —(�J
` Signature of Applic.MCammesr - - Dnm,
HAZARDOUS MATERIALS DISCLOSURE - RCrrOOfs' - !
Will the r I'wnl ft building f
pp b,t.Chapter
or and
theM1uomoand S tin 'type of Roof '
m defined by the Cupe i o Muri ipal Cnde Chnpter 9 12 .W sic Health alit S f Iy. {
Code,
C Y 25532m)? Ed No
- • . ,All roofs shall be inspected prior to any roofing material being insttdledo
wll m °I I f t b m' g e e t :ce9n 1 n . ride rip,al eh If a roofiis installed without firstObtaining an inspection; I agree to remove
emit ir : s_ ant arx ar s Jefnul by he Bay AmrAQu lfy Mttage mnl -
Di. ' all'new materials forinspec ion. Applicant.understatids and will comply with
❑Yids [d]No a -all n egulat o - sour ns.
I have d o ha a dminerals' 50 t' d Chapter fl95 f the �
Cerif n H hh&S t p uCode,Sections 25505 25533 d der C 1 le t dam
dthh Id' g l of cu t I th l f' y .p b'I'tyt notify the
scup squr menta h u. no le.ua of a Cen hem,f t
yt ppl' tit•= ' . Date , I,
o -All roof coverings be Classa`B"or better '
OFFICE'^,:.'