00100217 CITY OFCUPERTINO ' " ` '
RVi,DtNC DIVISION PERMIT' - CONTRACTOR INFORMATION:'")
aUII.DING ADDR ISS: PERMIT NO.
1671A
OWNER'S NAME: ^' ' APPLICATION SUR DATE. .
Qup 7 /
t -HONE: SANITARY NO: CONTROL NO.
\ � "
HILI LDING PERMIT INFO
I� ARCHITF.CI'IGNGINIiER: HLIIG ELIiC'IPLUMB MECII
azm
�aN
z 5 H z I:iceesltDCON'rltncn)R's DECLARATIONJob Description '
O I h by ft rat h t I am licensed d r p f Chapter 9(ci mmenc ng ,
h, aitS t 100) IDivision 3 fthe BusinessdProfession,Cale and my license �
"i hill 1 fl ,
raw6 ue CI « REPLACE WATER HEATER
�3LL
ARCHI I I CT'S UI CLARAT'ION
I ndersand ny plans shall be used s public record,
Dat -
r
a o LiccnsM P'nfessinnub
" ( i
OW NCR-BIIILUER DECLARATION
`—' 1 hereby.lien Nat I am exempt from the C vuur,Code:
s fiance Lew fnr the
ti
Fg Y fallowing reason.fSe..it ,713L5,m illunsx a'a Prolcssinns CM,:'Any my or comny '
Y O whleb requires manatee.permit re,tit ct,ulcer,impave,dn.nllsh,or repair any atmemle -
i3� pd be islcensedolso waretoircs thcapplicamfor Cotararmiuntilcaxi.(Chtemem -
matneisrewilhmm�..uotbepm, mnxo3ormfr,inrxl.meIromiot..,Car9 Sq. Ft. Floor Area Valuation
(umm�oncing wnnu fla of 70.IIB)al Uiviasis i i l .11,id esiond 4mfAny ss Code)
or that he is exempt themfmm and,he basis finial vl Icged exemption.Any violation
of Swint 7071.5 by any rp icon,far.permits objects theapplicant ma civil penalty;
nrnrn mann Nun five huMred dollars M(X)), APN Number - Occupancy -pe
❑Los owner of the pmpcmy,or my ennploycex with rages it,thciemle cnmpen.ation,
02
will do the-work,and the sanctum is eat ml=nled or ,nc,M4or cd,(sec.70.14, ~ .• Re aired Inspections
B.docs and Professions Code:The Contractor's License Law does not apply to an q p
owner of papery Who builds or Ingmoci,thereon,and who does such work himself
arm,ranghIn,two employeas.hroOffnithin'adilmprovane.Ismenormended m 502 — FINAL PLUMBING ENERGY '
offered for sale.If,however,Ibe huilding or improvement is sold within one year of '
completion,ole owner-builder will have thelwrden of paving that he did not buildor 506 — GAS TEST
p - -
mnve purpose o -
❑1.asowner ordue pmpony,min c.inwelyenatmeli.g with licensed contractors to 507 — FINAL PLUMBING..
anan.m tiro project(Sec.RILL Business.nd PoofieWnns Core) Hie CnnOacmrk '
Lissom Luw dies not apply,,mi of property who builds or improves thereon,
and who contracts Iia such projects with a council licensed pursuant to the -
C nnem.Ls License Law.
l uun exengrt.odes Sec. .li A,P C on,this reason -
Owner Date _
qWO11111i CO141117 A'I'ION DECLAItAr10N -
I hereby affirm under penalty of perjury one of the following declensions:
q .] 1 have and will inu mnia n Cenilcme of Consent to self-insure for W alao'x
Compensation. av provided f by Section TIMI of the LaMur Cri for the
pert, 1,1 k l I d':P t : 1 _
[I1 have
TI mint n W k C pe t n Insurance, req J by Section V, ^
3700,fire
I"h C de f me pert I cun,e fire cork fit fairthis perm t'x
iscut
iss ed My Workers C mpcnsu,ion marramilerancrand Poly numb rare O
Carrico Policy No: r _ -
CF.R'1'1FICA'I'ION OF E%EMP'NON FROM WORKERS'
COMPENSATION INSURANCE 1
(This xemlon need n'et be completed it tire permit is far one horded dnllun
(SI W)or less)
I artily that In the pedonou n e of the work for which this permit is issued,I
shall not employ any pecan in any banner so as to become subject to the Workers
Compensation Laws of California.Dine
Applicum - . ' .•
NOTICE TO APPLICANT:IL after ri ing this Cetilic,imat Exemption you should
Q 0 became subject to the Worker's Compensation provisions of the hNa Code,you must
forthwith comply wish ruck mookio o o,This permit skull be Jcancsl revoked.
Ln CONST RUCTION LENDING AGENCY
Ix 7 1 hereby name Inas mere is.eonNmetioa leading s=ay far the Pe,f.,p,.mc
.film work for which this permit is issued(Sac 3091,Co.C.) -
finder's Nam.
z Lender's Adders.
1 certity that 1 have'rcud this application.nd shite that the aNice information is
W 'e. ismi I agree m to iply with all city and county m lin.nce.s and store laws relating _ •'1
Q V to buildingcnnametion,mul h6ehynommitc reprexentaive.c ofthis city to enter upon °
rW the vlswe-meothand property for inspection ptUrcoc . ^
ti66 (We)ngnse to save,indemnify and kap harmlca Nc Cuy of Cupeninn agarol
h liabilities,judgments,costs and expenses which may is any way accrue against said
V z City in emeequence or Ne gaming of this permit. "
APPLCENI UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' Issued by: DateSOUR '
Sigmmmcof ApplieanVCnntractor Date Re-roofs
IIAZAIt MOUS MATERIALS UISCI,OSUItF. s
Will the applicant or lot=Wilding recursion amc or handle hw:Wuwa mutaiul .Type of Roof ,
to defined by the C.penfno Municipal CME,Cbepter 912,and the Hilth and Safety
C(vle,Semen 25532007, I I
11 yes °No All roofs shall be inspected prior to any roofing material being installed.
Will Ihc.pplirnnn,artonne hwldingo=nmantuse hieli If a roof is installed without first obtaining an inspection, 1 agree to remove
'mit ha...runs in,conmarommts as defined by the Day Are.Air Quality Management
)i,,ri„o vex' Cl No all new materials for inspection, Applicant unileisiands and will comply with
all non-point source regulations.
Ihave read the haenrd.us materials recommends under Chapter h.95 of the -
California Healm A,Safety Code,Senior,25505,25577 and 25531.1 understand but - -
iftheocildingdoev an currently have ac count,thin is my responsibility to notify the
oecupm of the requirements which must be met prior to issuance of a Cetifcate of
occupancy" Signature of Applicant Date `•
Owner oraudmnzedagent Date All roof coverings to be Class 'T" or better
OFFICE