03020017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
. . ins&*N' m . .. o,.
RU B.DING ADDRESS: . HOT WATER INC PERMIT NO.
7545 FALLENLEAF LA
OW NER'S NAME: 2531 GRACELAND AVE APPLICATION SUR DATE
NAZEEM NOORDEEN 02/06/2003
IONS (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECTIiNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
{ 00 LICENSED CONTRACTOR'S DECLARATION
z UZ F I hereby affirm Thal l am limned under pmvisons of Chapmr 9(armmcncmg Job Description
<i with Section 700)of Doo,on 3ofmc Rma est and Pntfcssions Codc,md my license is
�'" "fallmic`ond` t-.3G uox 3G/y REPLACE WATER HEATER �B��tLaE®
yg Lteose Clnii
O Contractor
to ARCHITE- I S DECLARATION
I undersand my plans shall W used as public records FEB 2 6. 2003
n p6p
0, Licensed Pndcuional -
pj OWNER-BUILDER BUILDING
W,
a S 1 hereby affirm that 1 am exempt from Ne Contractors License law for the
00 following nmxun.OSenion 703 1.5.Business and Pmfcssions Code:Any city or cuhmy
" which requires a permit to CnolWet,alter,improve.demolish.or repair any structor,
prior m iu issuance,also requires the applicant for such Permian life a signed statement
fzc that W is licensed pursuant to the provisions of the Commetors License Law(Chapter 9 Sy. Ft. Floor Area 0iolion
W (commencing wi In Section 7000)to Division 3 ol'the Business and Professions CtWq or
that he Is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of
not mom man five hundred dollars fs500). u Occupancy Type
Ei I,m Owner Of me Property,or my cmployccs wire w gu u mcir wle compenmtion.
will do Ne work.and the structure is not intended proffered for late(So,704L Businus 5112 —
an0 Pmfeuiom code:The contractor's License Law tires non apply m an owner of 506 — GAS TE ePulre nspec wns
pmpeny who builds or improves themon,and who doessuch work himself orlhrough his
momemployces,ptovided matauchimprovememiarenta intended oroffered formic.If, 507 — FINAL PLUMBING
however.the building or improvement is sold within one year of completion.Ne owner.
Wilder will ban the burden of proving that he did not Wild or improve for purpose of
salt,)
0 1,as owner of the property,am exclusively contracting with licensed contractors 4)
conswct me project(Scc.7044,Business and Professions Code:)The Contractors Li-
ceme Law does not apply to an Owner of property who builds or improves daemon,and
who contracts for such projects with a co aractor(s)licensed pursuant to the Contractors
License Law,
1 am cxcmpl under Sec. B&P C for this moon
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1
no and will mainain a Certificate of Corwenuo self-insure for Worker's Com ien-
vitu n,as provided for by Se<tion 3710)of the IaWr Code.for tW peaformance,of me,
work for which this permit s issued.
ave and will maintain Worker's Compensation Imuance,as mquircd by Section
3700 of me Labor Code,for the performance of Ne work for which this permit is named.
r am
Ca Worker s CompenxationI
;Cm P Policy No.:
rrier and Policy
nu/r��3��
Cartier.`( CHRT
CF,RTIFIC O OF COMPENSATION
EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
('This union need not be completed if Oa permit is fmonc hundred dollars(S its)
nr Icss)
I cenify that in the Performance of One work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Wmkcri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you xhouid
become subject to the Worker's Compcmxlion provisions of the Labor Code,you must
O O forthwith comply with such pervisions or this permit shall he deemed revoked.
z N CONSTRUCTION LENDING AGENCY
[+ l hereby affirm that more is a commeoton lending agency loo the performance of
1a me work for which this permit is issued(Sec,3(017,Civ.C.)
Ck1 Lender's Name
0' Lender's Address
a2
U O I cenify that 1 baro read dao application and sure that the above information is
Lr. P correct.I agree to comply with all City and county ordinances and state laws relating to
C)U building construction.and hereby aummixn represenalivcs of this city to enter upon the
r {!J above-mentioned propcny for inspection purpmcs.
F 0. (We)agree to save,indemnify and keep harmless the City of Calcium,against
ZI Until ities,judgments.cots and expenses which may in any way acerae against said City
U Z in consequence of the graining of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ' 1� `�3
_A�k
SOURCE REGULATION
����•YY• /�"Qe—`� (•�07 Re-roofs
srglr CAPNreaHAZARDOUS RE as
tooMATERIALS DISCLOSURE Type Of ROOF
Will be applicant or fumrc building occupant store or handle hararduus mamdal
as defined by tW Cupcnino Municipal Code.Chapter 9.11,and the Health and Safety
Code
E]Yes 1553z1ar1 All roofs shall be inspected prior to any roofing material being installed.
❑lit �mu
Will the aI,comm rfum building oath antusce Ifs roof is installed without first obtainin an inspection, I agree to remove
Occupant equipment or devices which g
70141`u�dgcm
itict' us airummmiZm,g�.:rialv
cincdbydac13ayArcaAirQualityManagcmcnt all new materials for inspection.
District'
❑Yes
I have read the harar, requirements under Chapler6.95ortheCalifor-
Health&Safety Cvak.SmOnns 25505.25533 and 25534.1 undenund thatofthe holding �
x nm curtently have a mnam. t my expansibility to notify the occasion of the /`�1 �ij ,="'�'� rLG ��
ormaIms which mas,W 'auto. aoce ofa emfic,or is l
F � Signature of Applicant Date
� �': All roof coverings to be Class "B" or better