01020137 CITYBUILDING
my SIONNv CONTRACTOR INFORMATION:
PERMIT
BUILDING AUURIisS: - PERMIT NO.
7590 ERIN WY HI IIMBING
_
OWNI.R'SNAMii: APPLICATION SUR DATE '
SWANSON PAULINE E 1 -
�AONE: SANITARY NO. CONTROL NO.
aOp A RCI it I ECTILNG I N T:ER: _ HI111.UING PERMIT INTO
z E BLDG ELECT' PLUMB MECH
S N j LICENSED CONTRACTOR'S DECLARATION
I hereby tuition
that 1 am licemed under provisions of Chapter 9 _ Job Description
2,E„C,py with Section 7000)of Divi>ia,3ot tM1C Husincxn and Promsninnx Codc.nd myll,etuc P
n full force and cl'fcet.
�ae Le"n ,Class Lie'" WATER HEATER REPLACEMENT
p a O Dal, Comracmr
ts' ARCHITLCI"S DECLARATION
F'LL s, I understand Illy plan.shall he used as public reemol,
ino Lmemed Pndeumonul -
c X oOWNER BUILDER DECLARATION `
,4—m 1 herchy aflina That 1 am exempt Iron,We Ouhrac or'e License Law for the
following rearnn.IScnion]0315.B usinc,s mW Pn I...ions Code:Any d1y nreoumy _
5. p which requires a Ic'rmit to ctaromcf alter,initiative,demolish,or repair any structure
ce
co prionens iuuunce.also equire_s thea licunuor such
asm PP permit mliloasigned.eu¢n,ent
matneis licensed pursuant to the provisions of the Contmeter:s License law(Chapher9
(commencing with Section 7su)ofDivision 3onneBuslne.andProf e..innxn.le> Sq FL Floor Area
Valuation
or that he is exempt them-from and the basis for the alleged exemption.Any violation -
of Sectlan 7031.5 by any applicant for a permit sunjecu the applicantto a civil penalty
of not more than five laalred dollars($500). APN Number Occupancy p
❑I,alowna.f the poo,cnxnr,,,y,mpwyeex win,wager as tneh,oI.cmnpenxwia,,; 35921023.
�. ,��
I'll do be work,and the structure in not intended or otlend Ins sale(Sec.]IW4,
Bmira a and Profe,00rs Code:'rhe Contractor,License Law aces urn apply ro a - Required Inspections
r of priTer y Who builds or in,pmves thereon,and who d 'such sod f
or through his own employees.provided that such improver,enu are oat,man' _ FINAL PLUMBING ENERGY
offered ser sale.Jr.however. he b„tldi„g m improvement i sore sus nm on 'art 50c —
complenfn`Iheowner-0uiid,rwillhavel he burden ofpnoinglhmhedidn old or 5@Fs — GAS TEST
tnproPurr
❑I a f its p p nY 1 Iront Iin, if licensed ' 1 1 r:ro' S@7 —: F'I NRL PLUMBING '
oat o to p J t(s ]Liu H .- d e r.. :il, )Thec tinct r .
and 1 e or such
t e n property n n 1d - p mere,,
and whocomet. far ch project%with tructorLT licensed pursuant to the
Contractors,Lice,law. ,
❑I um exempt under Sec. ,H h P C for This mown '
Owner Ube
WORKER'S COMI'ENSGrION DECLARATION
I he cby infirm under Mnalty of perjmY one of the following dudara......
] I have and will maintain a Clothed'of Comcnt in 1ITimure for Worker's
Compensation, as provided for by Section 3701 of the Ichor Code, for the
performance of the work fns which this permit is issued.
❑i have and will muinluia Worker's Cn Te,u:nim,Inmrunco.ux required by Seen un _
3700 of'the Luhor Code,for the Perfortnunce of the work lint which Ihls pennh is
issued.My Worker's Co,npenwtion Insurance cro er and policy number me: s -
Cartier: Policy No.: '
CERTIFICATION OF EKIiMPTION FROM WORKERS'
COMPENSATION INSURANCE
Chi,section need nal be completed If the peanil is for one hundred dollars
(511 k1)or lows,)
I certify m:n In the performance of Ire work far which,his gcomf s issued I '
sha11 not employ any pi in any manner so as to become subject to the Worker,
Cnmpensmion laws of California.Data
Applicant
Nf mCE TO APPLICANT:If,attar reeking this Ccnificom of Exemption,you should
7 hecomesubject to the Workers Compenxulinn prov,smas of the Lulu,r Coda you mml
O forthwith en,uply will,such pmvIII onx n,this permit shall be dearal revoked.
fr ,fir CON Sere is a]ON LENDING AGENCY
1 henry allich that there iss infiltrator(See,
lending agency tie the performance
of the work for which this pcmdt is issued(Sec.3097.Civ.C.)
G z Isnder',Name
Isnder's Addrccs -
fj+ I rfyd1l flim dth aprl .ni d as Ihth M1informalinn is
Lir .
Fs ,.Y1.1 get t ,ply with II ity auld c 1, d' I ,are I retain,
0 (� horldin I fnt., dh h II p ti vnllh"pt true,
,W, the abovemm-1,onnl property for;mpoetion pl'o”.
[ti Gr (We)agree taxes,indemnify and keep Initiates,the Cay of Cupertino against
:A liabilities,judgments,Costs and expenses which may in any way accere against said
t.J Z City to comequ..ce of the granting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Issued by: Date e•
sigmnme ornpphca
HAZARDOUS MA] Date Re-roofs
'IikIALS DISCLOSURE '
Will th,upplicam or tumrc building ooup.in store m handle humNous materiel Type of Roof -
as defined by the Cupertino Municipui Crate,Chapter 9.12,and the Health and Safety
Cale.Section 25532m)J
❑Ye. 13 No All roofs shall be inspected prior to any roofing material being installed.
Will the apphranninamare lmtlnisl by'he 0ayne aAi,QrladM,ca,c I.,, If a roof is installed without first obtaining an inspection, 1 agree to remove
,it hanoMuue auldilul ru naticba0nng by'he Bey Arcn Air Quality Mific,, nen, g p
`hsriol❑rex 11 No PP" all new materials for inspection. Applicant understands and will comply with'
all non-point source regulations. -
1 have read the huallous malcmd,requirement.under Chapter 695 of the '
Coldomia Health&Safety Code Sections 25505,25533 and 25534.1 undentu„d that '
if the Witch.,does not currently have a enam,that;tis my ns".'inility to notify the
occupant of the requirements which must he met prior o issuance of a Cenircme nr
o,enpaney. -
Signature of Applicant Date
-wouroraatnonicaagent Date All roof coverings to be Class `B"or better
OFFICE