01050022 CITY OF CUPEBTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bun,ulNcnnm2T830 EDWARD WY WATER HEATERS ONLY PERnf1TNo. 01050002
OWNERS""buIVEN RICHARD P AND LINDA L 500 AIRPORT BLV APPLICATION S&/A%2/2001.
PHONE: SANITARY NO. CONTROL NO.
(1415)-349-3747-
a a z AItCI 1IT17C'I'/ENGWEER: BUILDING PERMIT INFO
C BLDG ELECT PLUMB MECH
vsd
�a, I.ICENSEDCONTRACTOR'S DECLARATION Job Description
cz d I nerebr mrrnt ma,1:m,licensed under provisions of Chapter 9(rnnnmrneing P
F�Cat whnf.tlorceand�rn'Ivi,ann2nnbennwine. and rmr inn.etwc.nnamrreenm REPLACE 50 GAL GAS WATER HEATER.
m^ is in lull force trod effect.
`e 6 License Class Liv,g
C
an C Dam Contractor
3 a G ARCUI IIiCI'S DECLARATION'
I understand mrplans slant b:nscA a puIr e�oN.
-
Ew�^
af ce M 0O LicenseProfessional
Licensed Pfessional
OWNER-BUILDF,R DECLARATION
1'1. 1 herehy o(fmt that I vat exempt Gnm the Cnntrnd r-N Lecno,law far the
r_i a following re...to(Section 703 1.5,Ba%ineis road Four..ions Cod,Any city or county
z 4D which requires a permit to comodow,alter,improve,demoli,n,or repair any structure
re
5 ir pr ce,also .4 thepp1 t l a P.rm fl signed statement
That be is rwen,cdhat, m p Wine. 3 c leader,r : 1z (Charter Sq. FL Floor Area Valuati000
or g ,h Section701.. !Divi` l !the H,od met in4 a t Calc)
of Shat he is 31.5tb Ihererom and he hals for the subjects
the cxrmain to Any l violation
ere on
of BaClinn 7!131 5 by any applicant for v permit subjems the uppllcvn,l"o civil genrolty
,if mor more man rive h,mdred dollars(aSBm. APN•�Lv Pb@,012. 00 Occupancy Type
El 1,as owner of She popery,or my employees with wages as their sole compens.eme. (-,]ft
will do me work,and the structure is not intended or oflcred lir sale(Sm.7044,
Business and Pock%ion..Code 'rbc Cmttracmi.License Law duos nm apply m an DlrI
mr of progeny Who builds or improves thereon,and who do,ouch wore himself 502 — F I HL LUIII l N(.i ENERGY
through his own employer,.nm.;deal that such intgrovenems are not intended or
ufLLred for orae.If,however,Inc building or in,pmvermat is sold within one yea of 506 — GAS TEST
nmtnmdtrr ntr"wnrrrmvi d.'r will rune nm boronfp
aroon,flat he did.'It Wim's` 507 — FINAL PLUMBING
improve purpose n
0 I,as owner of me urr,rf,,ten escitoorly comruding with licensed contractor.to -
mnonml the project(Sce,Alio.Business and Pmfm'.rions Coal The Contractor'.
License Law does nod apply wan owner of prnpeny who build,er improve,IbflTal,
and who ntrwfor el,mojec,.s wmorn)with u cnnwliccnmrl furnace to The
or-.ron m
bie, law,
[3l am rxcntPI under Sec. .B Fr P C for this reason
Owner Date
WORKER'S COMPENSATION pri ryon DECLARATION
Ihe¢hy affimnundcr pvrmlly of gegury one of The fallowing declarations / ^
❑ 1 have and will maintain a Cby fi,i of 3700 i to t ulf be, for Worker's /
CoformanceI he porr fee for by Berrien Tlsu of the Luhor Cwle, for ,he -
grrtonnvnce of,he work for which nhis pumtir i,i.wcA. )))
❑1 have and will maintain Worker's Compensation In.urance,as required by Section
370I of the Labor Cod ,for the Iwroolance of the work for which this Twort i,
,sued.hey Worker,Cnmpereation Inwrance carrier and Policy number aro
Currier: Policy No.:
CERTIFICATION Op EXEMP'1'1(IN FROM WORKERS'
COMPENSATION INSURANCE
(Phis%action iced not he contpleari Hie g.rmit is for one hnndmd dollars
(51(X)or Icus.I
1 verify that in me prrhsmnrmc of the work for which this strmL i.i..ucd.1
%hull not employ any person in any manner so as to become subject to the W'erkam'
Cnmpensvllun Low,at California.Dar.
Apquem,
NOTICE'TO APPLICANT:It,vit,,neking thi..Cenitinn of Exemption,you should
became subject Ir the worker,Compeaminn provisions of the Labor Code,you meal
fonhwlm enn..ly with ouch I,,I,kiea ur this permit.hail he deemed rr,mI
z �
f` h
CONSTRUCTION LENDING AGENCY
a ' Ials I or affirm thinpermisaamed(See. leading agency for the prrfnmtance
'If work fur which Ihia permit is IswrJ(See.3097,Civ.GI
G A -
Cruder'%Natnc
U Z Under'%Address •
I«oily that I have front this application and amlr That the above information i,,
F.ecomet.I agree m comply will,all city and musty orJinunce;Dna,late Inns relating
U to huil,ing construction,and hereby amherire represento(uus rf this cllym enter upon
ry] the above mentioned progeny for inspection purpom., _
F. 0. I Wu)agro to save,inacmnlfy and keep hermits She City of Cupenin..gains,
Vi liabilities,Indigence,..,coos and tv ,ease%which may in any way accrue against said
U ,Z City in sa dvismancc of She griming of this permit.
APPLICANT
U S
DERSTNDSANDWILL COM PLY WITH ALL NON-POINT
SOUR( Issued by: Date
Signatreof AppbcantrCmanteter Dam Re-rook
HA%ARDOUS MATERIAI S DISCLOSURE
Will the appli.nrorname building recol slow nrhandlelacerations mineral Type ofRoof
,o drnnel by the Capeninn Mnnicipul Coale.Charm,9.12,and the Health wad Safe,y -
Cedr.Section 25532fv1'I
❑Ye, °N" All roofs shall be inspected prior to any roofing material being installed.
Will lhug,glicanlor IivurcbuildingcecupantLee equipment ordivorceswhich If a roof is installed without first obtaining an inspection, I agree to
rntithvmnluu..air cmcnnin;mua.dctincJ M1y rM1e B.ay Arca Nr Quality Mnnugrtnem 6 P .g remove
Di.,rier. all new materials for inspection. Applicant understands and will comply with
0Yf, 13 No all non-point source regulations. p y
1 have read Ilse haeardon,namrialn requirements under Chapmr 6.95 of the
California Ilea d,k Safety Cede.Sec,ions 25585,25533 and 25534,1 understand Ilett
iflhe huilding does nal currently have a mount, bar it is my responsibility to ratify the
Occv epmv'If'he requircmmaL.which mus be mel prior m issuance of a Ceniliva a of
cupancy. Signature of Applicant Date
owncrsitlnem"r,eA:egem nate All roof coverings to be Class "B"or better
OFFICE