03010184 CITY OF CUPERTINO
Buu.Dlnc Dlvlsu)N PERMIT CONTRACTOR INFORMATIONo-:
ISO ILD]NO ADDRESS: HOT WATER INC PERMIT NO
7602 ERIN WY 03010184
_ OWNER'S NAME: 2531. GRACELAND AVE APPLICATION SUB DATE
( LYDIA MORALES - 01/28/2003
ONE (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHIT iC'VENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 o
00
LICENSED CONnsedUnderPDECLARATION
p 1 hereby affirm that I r3 licensed under and
Po esso( Conic. 9(commencing Job Desen [Ion
yzw wi,M1 Seca n]I01)of Divisi(onln(the Busir�anJ Profexsinns Cute.and mylicensc is �0�r .A. @ [L°17�
Toy in fu nand c(f• ✓ �r (y REPLACE WATER HEATER N ALlL—=Q3
ass 16
=aim Dam�Cngalnr FEB 2 4 2003
RCIIITEGTS R TION
I edermanJ n y plans shall he uscJ as puM1lie records
U
Oy
t-LLo Licensedpmfe i(onzl BUILDING
OWNER-BUILDER DECLARATION
y<� I hereby affirm Thal I am exempt from the Contractor's License Law lu othe
w a O O following reason.(section 71131.5.Business and Professors Code:Any city or county
a w$ which requires a Permit m Construct,alter,improve,demolish,or repair any sommure
Foy phorto itsissuencualso rcgnires the applicant lorsuch peroriuo rile a.signed.dxtement
`e thalncislicensedpursuant tothe provisions othe ComanorsLicense Law(Chaptcr9 Sq. Ft. Floor Area $'$."tion
C,,1— (commencing with Section]O(yl)of Division 3 of the Business and Professions Gale)or
W3§ that he is exempt ehembOm and She basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit sublimes the applicant to a civil penally ofe Occupancy Type
not more Nan Eve hundred dollars($50%
❑1,as owner of the properly.Or my employees with wages m their sole compen arimm,
will du Ne work,and thcs,rllcture is not intended or offered for safe(Sec.]D14,Business Zuz —
and Pmfossions Cade:File Contractor's License law docs not apply to in owner of506 - GAS TE eJgwre nspec Ions
protocol who buildsor improves thereon,and whodnes such work himself or through his
Own employees,provided that such improvements arc not ntended oroffered for side.If, 507 — FINAL PLUMBING
however.the building or improvement is sold within one year of completion.She owter-
builder will have the burden of proving Nat he did not build or improve for purpose of
talc.).
❑1.as Owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7844,Business and Professions Code:)The Contractor's Li-
cense law does not 3PP1Y to an owner of property who builds or improves themon,and
who contracts(or such projects with a contractors)licensed pursuant to She Contractor's
License Law.
El I am exempt under Sec. B&P C for this reason
137M
r Date
WORKER'S COMPENSATION DECLARATION
/ I hereby Motion under Penalty or perjufy one Of the following declarations:
,Jave and will maintain aCeniticate of C.nwntto self-inure for Worker's Compere
,az provided for by Section 3710 of the labor Code.for the perfmmancc Of the
for which this permit is issued.
ate and will maintain Workers Compensation Insurance,as required by Section
fthe labor Cork,fO the performaannnce of Ne work for which this permit Is'ssued1: p tJ "IC nEt{tA "Zor( policy
NCC
numl—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is lnrmm hundred dollars(SIM)
nr less)
I ceni(y that in the peninmance of She work for which this Permit is issued.I shall nm
employ any person in any manner so as in become subject to the Worken'Compensation
Laws Of C.l,farmu.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cer iticae of Exemption,you should
become subject to the Worker's Compensation provisions of enc tabor Code,you mus,
O O forthwith comply with xueh pinsist nns Or this permit shall he deemed revoked.
z y CONSTRUCTION LENDING AGENCY
(-� I hereby aotifm Our there is a comre"unn lending agency lot the performance of
Ci the work for which this Permit is issued(Sec.3097.Civ.C.)
ft1 Lear 's Name
0. lender's Address
az
J O 1 cenily that 1 have read this application and sure that the above information is
lL F' correct.l agree to comply with all city and county ordinances and state laws relating to
OU building conotmetion.and hereby authnrim mpremolaoces n(this city to enter upon the
above mentioned She gorrog inspection purposes. l
F 1 (We)agmen hs save,indemnify and keep harmless the City of Cupertino s against
(� liabilitiesi afire to case..Inde nify and keep
Modmay in any way a"cone against against
Coq
U z A consequence Of UNDERSTANDS
Of this Permit.
.. APPLICANT UNDF.RS'rANDS AND WILL COMPLY WITH ALL NON.dolr.� Issued by: Date I
SOUR $LGU ATIONS. v,(
nmum ofnppbcaniconwcmr '��O 9 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building(occupant store or handle harallous m ncrial
as defined by the Cupcnim,Muni"' al Code.Chapter 9.13,and the Health and Suety
Cole.Section 25532(a)'1
❑Yes N(o All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building occupant use equipment If a roof is installed without first obtaining an inspection, I agree to remove
PP b p qui t or devices which g p g
itict? usair mn,amiwn¢asdefncdnyNeBryArea Air Quality Management all new materials for inspection.
D'arict7
❑Yes
1 have¢ad the MnNnusmamrials myuirementr under ChaPer[.95 o(thc CaliRu-
niu I IcuIO&SulcLYCIJ.Sections 25615.25533 and 25534.1 umkrsund thm if the h oldmit
Jtc..nm cnlly nave u Nnant.Wut it is my respm.i M1iliq In n(otil
the p the
regal �,uw'nm°.,nem`tpti"`°'i:`a,n"°r'c, i� " t of Signature of Applicant Date
Owner(it authorized agent Date All roof coverings to be Class "B" or better