01050074 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDR7940- FALL CT JUST WATER HEATERSPjWLND' 01050074
ow'mtRs NnMEHAGAN JAMES R AND LINDA J TRUS 1.764 NATIONAL AVE AI'PL'cn'IIONs1 �IN8/200].
(510) 293-9901
PHONE: SANITARY NO. J CON'IROLNO.
M m G m� ARC'HI'IECTIENGINRER: BUILDING PERMIT INFO
lie BLDG ELECT PLUMB MECH
�z
w,j LICENSED CONTRACTOR'S DECLARATION
z 1 hemp,nffrtn manm t 1 rcemW ander pmvinh+a,u Chapmr 9 bmtnualary, Job Description
G_:� with Section 7")of Division 3 of the Business and Professions Cale.and my license
is infuBrorceandeffect. REPLACE 40 GALLON GAS WATER HEATER.
s a Date clans Lica
�a5 0 Dam
W 3 tL fin ARCHIT'ECT'SS DECLARATION
�'W=°g I andemmraJ my plan.,dhall W used u.,public recnmx
i p q Licensed Prnfclan al
Fi OWNER-BUILDER DECLARATION
1 herby affirm that I any exuttgt finny the Culinary a s License law far the
h Z billowing reusoo.(Section 7031.5,Business and Pmrexsions Cale:Any city or county
ze F C which requires a permit to mnswet,alter,improve,demolish,or repair any structure
P. prior to its iwtmnce.ulsa requiresthe npplirmt forsuch,manil to filensignW umtemenu
a. that he is licensed parstimat to the proviocure(if the Contractors License Law(Chapter 9 Sq. Ft. Floor Area ValuatiQQft,
hemo newing with Section 7000)of Division 3 of me Business and Professions Cade) $IJ75
or that he is exempt Ihetefmm and the basis for the alleged exemption,Any violation
of Section 701.5 by any upplimmt For u pamdt subjects the upplicant to a civil penalty
of.,it mare than five hundred dollars(s500). - APN Number Occupancy Type
❑1,as owne,ofthe,m r ora;-enloees with waves ns thaicxolccnm tion, 0621.3006. 00
th Y ) P Y b pcn.vu
will ne the work,and the odiloracture C not intended or offered for mo apply toed,
Baxfne.x and Itaressmns cede:The cammemr'x License Law dcex not apply to an Required Inspections
of pap nr woo ntmdx m inproven mcra+n.and was ane,..nn wt+rk himxeff 502 — F I
ML PLUMBING ENERGY
or through his own employees.provided that.such improventemx are not intended or
offered for sale.IL however,the Wilding or improvement is sold within one year of 506 — GAS TEST
completion,the owner-builder will have the burden of proving that he did net build or
hnpmve fir purpom or sale.), - - .507 — FINAL PLUMkING ,
❑1,a,owner of the mr,tr .y,au a mli nhalr cantmcdng with licensed cnmrneor,,to
construct the project(Sec.7044,Baxlnas and Professions Cish:)'The Contractor's
License Law does not apply to an owner of property who Wilds or imposes thereon.
and who contracts for such projects with o commends)IimncW pursuant to the
r'x License Low.
0 1 any aent exempt under Sec. .N&PC fire mix reasonO '
Owner Dam
WORKER'S COMPENSATION DECLARXI'ION
Ihereby affirm under penalty of perjury one of the following declarations.
O 1 lime ani will maintain a Certificate or Consent m self-insure for Worker's
Compensation, as provided for by Section 37M ur the Labor Code, for the
red onnanm of the work for which this pennil Ix ixmed,
❑1 have and will maintain Workers Compensation Insurance.as required by Section
37gt of the Lahor Code,lin the performance of the work for which this permit Is -
maid.MY Worker's Compe"suf on Insurance carrier and Policy number are:
Carrier: Polley No.:
CERTIFICA'T'ION OF EXEM19'ION FROM WORKERS' -
COMP ENSATIONINSURANCE
(Thi,Seaton need oat be emnplctW il'the penal is rnr one hundred Jnlhas
(S 100)or leer)
I certify that in the perrormancc or the work for which till at i(iv..nued,I -
shall not employ any person in any manner so as to become object In the Workers'
Compensation laws of California.Data
Applicanl
NOTICE TO APPLICANT:It,ulcer narking this Cenilieate of Exemption,yon,,huuld
become subject to the Workerx Compensation provisions of the Labor Code,you must
Q Q farm.di comply with such provision,or Thi., .fish.])bedeemed msoked.
Z 2
F 14 CONSTRUCTION LENDING AGENCY
CL > I herchy&Ilion that them is a curnmtaion lending agency for the performance
of me work In which de,count is issued(Sc,3097.CI,C.)
L Q Lenin's Name
Q z Lender's Address
V C) I cerci If that l have mad thisap,1,.txm and mate that the above i mnimtatiun ix
ti Fs correct.I agree to comply with all city and county ordinances and state laws relating
0 U to bit lying coustuad and humby authorize represcramyoas of t his city to enter upon -
r� Ihe above-mentioned Pn,pery tier inspection purposes.
E„ 4
(Wed agree tosac,indemnify and keep harmlcxrthe City of Cupertino against
� to liabilities,judgments,costs and expenses which may in any way acemu against said
V City In m os,yease of the'outing rel this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS. y'
Signature of ApplicundCommeur Date Re-roofs
HAZ RDOUS MATERIALS DISCLOSURE
Will the anplmtm nr future building rmptpant stem or handle ha,tudons muedal 'type of Roof
as defined by Ihe Cupertino 6lunicip:J Cade,Chapter 0.12,and the Health and Safety
Code,Section 25532(0)?
0Ye` E)No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or derive.which If a roof is installed without first obtaining an inspection, I agree to remove
cont hazardous air contaminants as defined by the Bay Area Air Quality Management
Dfdt all all new materials for inspection. Applicant understands and will comply with
oral 0 N all non-point source regulations.
I bow mail(he hmerduus materials mquimownts under Chapter 6.95 or the
Calil'omia Health&Safety Code,Sections 25505,25533 and 25534.1 undersand ohm
Billy,building does not currently have rate...,mat it ix my re, ,nobililym nmirythe
Occupant of r m
the requienta met which must be prior to is.-ince of a Certificate of
ctp:mcy .
Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class `B" or better
OFFICE
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDR7940- FALL CT JUST WATER HEATERSPjWLND' 01050074
ow'mtRs NnMEHAGAN JAMES R AND LINDA J TRUS 1.764 NATIONAL AVE AI'PL'cn'IIONs1 �IN8/200].
(510) 293-9901
PHONE: SANITARY NO. J CON'IROLNO.
M m G m� ARC'HI'IECTIENGINRER: BUILDING PERMIT INFO
lie BLDG ELECT PLUMB MECH
�z
w,j LICENSED CONTRACTOR'S DECLARATION
z 1 hemp,nffrtn manm t 1 rcemW ander pmvinh+a,u Chapmr 9 bmtnualary, Job Description
G_:� with Section 7")of Division 3 of the Business and Professions Cale.and my license
is infuBrorceandeffect. REPLACE 40 GALLON GAS WATER HEATER.
s a Date clans Lica
�a5 0 Dam
W 3 tL fin ARCHIT'ECT'SS DECLARATION
�'W=°g I andemmraJ my plan.,dhall W used u.,public recnmx
i p q Licensed Prnfclan al
Fi OWNER-BUILDER DECLARATION
1 herby affirm that I any exuttgt finny the Culinary a s License law far the
h Z billowing reusoo.(Section 7031.5,Business and Pmrexsions Cale:Any city or county
ze F C which requires a permit to mnswet,alter,improve,demolish,or repair any structure
P. prior to its iwtmnce.ulsa requiresthe npplirmt forsuch,manil to filensignW umtemenu
a. that he is licensed parstimat to the proviocure(if the Contractors License Law(Chapter 9 Sq. Ft. Floor Area ValuatiQQft,
hemo newing with Section 7000)of Division 3 of me Business and Professions Cade) $IJ75
or that he is exempt Ihetefmm and the basis for the alleged exemption,Any violation
of Section 701.5 by any upplimmt For u pamdt subjects the upplicant to a civil penalty
of.,it mare than five hundred dollars(s500). - APN Number Occupancy Type
❑1,as owne,ofthe,m r ora;-enloees with waves ns thaicxolccnm tion, 0621.3006. 00
th Y ) P Y b pcn.vu
will ne the work,and the odiloracture C not intended or offered for mo apply toed,
Baxfne.x and Itaressmns cede:The cammemr'x License Law dcex not apply to an Required Inspections
of pap nr woo ntmdx m inproven mcra+n.and was ane,..nn wt+rk himxeff 502 — F I
ML PLUMBING ENERGY
or through his own employees.provided that.such improventemx are not intended or
offered for sale.IL however,the Wilding or improvement is sold within one year of 506 — GAS TEST
completion,the owner-builder will have the burden of proving that he did net build or
hnpmve fir purpom or sale.), - - .507 — FINAL PLUMkING ,
❑1,a,owner of the mr,tr .y,au a mli nhalr cantmcdng with licensed cnmrneor,,to
construct the project(Sec.7044,Baxlnas and Professions Cish:)'The Contractor's
License Law does not apply to an owner of property who Wilds or imposes thereon.
and who contracts for such projects with o commends)IimncW pursuant to the
r'x License Low.
0 1 any aent exempt under Sec. .N&PC fire mix reasonO '
Owner Dam
WORKER'S COMPENSATION DECLARXI'ION
Ihereby affirm under penalty of perjury one of the following declarations.
O 1 lime ani will maintain a Certificate or Consent m self-insure for Worker's
Compensation, as provided for by Section 37M ur the Labor Code, for the
red onnanm of the work for which this pennil Ix ixmed,
❑1 have and will maintain Workers Compensation Insurance.as required by Section
37gt of the Lahor Code,lin the performance of the work for which this permit Is -
maid.MY Worker's Compe"suf on Insurance carrier and Policy number are:
Carrier: Polley No.:
CERTIFICA'T'ION OF EXEM19'ION FROM WORKERS' -
COMP ENSATIONINSURANCE
(Thi,Seaton need oat be emnplctW il'the penal is rnr one hundred Jnlhas
(S 100)or leer)
I certify that in the perrormancc or the work for which till at i(iv..nued,I -
shall not employ any person in any manner so as to become object In the Workers'
Compensation laws of California.Data
Applicanl
NOTICE TO APPLICANT:It,ulcer narking this Cenilieate of Exemption,yon,,huuld
become subject to the Workerx Compensation provisions of the Labor Code,you must
Q Q farm.di comply with such provision,or Thi., .fish.])bedeemed msoked.
Z 2
F 14 CONSTRUCTION LENDING AGENCY
CL > I herchy&Ilion that them is a curnmtaion lending agency for the performance
of me work In which de,count is issued(Sc,3097.CI,C.)
L Q Lenin's Name
Q z Lender's Address
V C) I cerci If that l have mad thisap,1,.txm and mate that the above i mnimtatiun ix
ti Fs correct.I agree to comply with all city and county ordinances and state laws relating
0 U to bit lying coustuad and humby authorize represcramyoas of t his city to enter upon -
r� Ihe above-mentioned Pn,pery tier inspection purposes.
E„ 4
(Wed agree tosac,indemnify and keep harmlcxrthe City of Cupertino against
� to liabilities,judgments,costs and expenses which may in any way acemu against said
V City In m os,yease of the'outing rel this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS. y'
Signature of ApplicundCommeur Date Re-roofs
HAZ RDOUS MATERIALS DISCLOSURE
Will the anplmtm nr future building rmptpant stem or handle ha,tudons muedal 'type of Roof
as defined by Ihe Cupertino 6lunicip:J Cade,Chapter 0.12,and the Health and Safety
Code,Section 25532(0)?
0Ye` E)No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or derive.which If a roof is installed without first obtaining an inspection, I agree to remove
cont hazardous air contaminants as defined by the Bay Area Air Quality Management
Dfdt all all new materials for inspection. Applicant understands and will comply with
oral 0 N all non-point source regulations.
I bow mail(he hmerduus materials mquimownts under Chapter 6.95 or the
Calil'omia Health&Safety Code,Sections 25505,25533 and 25534.1 undersand ohm
Billy,building does not currently have rate...,mat it ix my re, ,nobililym nmirythe
Occupant of r m
the requienta met which must be prior to is.-ince of a Certificate of
ctp:mcy .
Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class `B" or better
OFFICE