00100185 CqvDOF CUPERTINO
n.DING DIVISION PERMIT CONTRACTOR INFORMATION:
-�`,` BUHy. NG ADDRESS: - PERMIT NO. -
YY 1.001.as `
OWNER'S NAMF;: APPLICATION SUB DATE
H GTI I TAP,
/^7/2000
PHONE: SANITARY NO. CONTROL NO.
3 ^ •
pl O O ARCfII'I'NC'P/ENGINEER: BUILDING PERMIT INFO
g uo F BLDG ELECT PLUMB •MECH
Z S 3 - LICENSED CONTRACTOR'S DECLARATION Job Description
O Z Zf p I hereby affirm that I mon het rued under provisions of Chapter 9 people ming P
P so`v 1° with Section 700001 Division3ofthe Buduensand Polfesxions Code,and ro'zi,rme
iin hall farce rand elrect.
memacmee Liea
3��, Dare 0optima
REPLACE 40 GALLON GAS W TER BEATER
° -
p ARCHITECT'S DECLARATION
,aj I onde rt d my pl .hall he used as public records
Licensed Professional
JA I
°a m OWNER BUILDER DECLARATION
11 by affirm tht1 t from Ire ft ant the
I - for
Billg (Section]03L5 ctnI I f Code:A Y dy county
q eeit d a Fl demolish, pY acre
m (ht t o ,al,v raccum,me
TN
rr,picz I M1pera fl s 'fined Chapteem
-morn licensed paean r t d provisions Divori or Contractor maci License L,ss on,Cod ) Sq. Ft. Floor Area Valuation
(commencingrhat heis a wrap Swarm 7a00)of Division 3 of the B led cipand Processions Coale) -
or Shut he is 31.5 bS therefrom and the Hoorn for the objects
the exemption Any l plmlan _ 1
of Semon client
5 by any applicant for u pernn cubjwts the application o civil penult
pr Hat mare man ave hundred ammo(ssldl). � � y AP-N Number _ Occupancy Type
❑I,tis owner ofp
the mpenymas.rally employees with wages their sale areopemnban, - -
willdu the work,and the structure In not Intended lir offered for sale(See.9044. 375390515. 12
Easiness and Prmv,ian,Cole:The Commercial's License Law does ant apply man Required inspections
pper of property Who builds or improves thereJon such and who Josuch work himself '
oo through his own employees,provided that such improvements are liar intended or '
-offered for sale.If,however.the building lir Improvement is sold within one year of Sat — FINAL PLUMBING ENERGY
completion, r whave mt
ion,the owner-baddeill hthe landof mnvmgmnt he did apt hadd ar
Improve forparpose araale.> w-raF., — GAS TEST
❑I,a,owner ii properry.are eaemsively aontmining wits,caused onplowpor,to 507 — FINAL PLUMBING
- ongmct the pmjem(Sat.70W4,Bnsiacse and I'mfessians Cude)The Contractor's -
License Law does not apply to an owner of property who hudds ac improves thereon, <
and who contracts for such projects with o cammmroo licensed purmard in the ..
Connector's Licanse Law.
'D I am exempt trader Sac, ' ,B&P C for this mmen• _
Own,, Date ,
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Finally of perjury one of the following declarations:
O I base olid will maintain a Canlflcate of C( wan In self-insnra for Worker's
Compea-frau, a, provided Car by Section 3700 of the Labor Code, for Ire
performance of the work for which this permit'is issued,
❑1 have and will maintain Worker's Compensulian bloomer,as repaired by Sardi a ' t
3700 of the Lahor Code,Lor the pedomaoce(if the work for which this period is -
issued.My Worker's Cpmpmro'ation Insurance carrier and Policy number ore -
Carrier: Policy Na:
CERTIFICA9'ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE t
(This sectino'nced not be maidetetf if the Permit is for one hundred dollars '
($100)or Ices,)
I cenify Ihat in She performance of the work far which this permit is issued.,]
shall no employ any lwcnn In any manna,-as to respite subject ut the Workers'
Compensation Lawn of California.Date
Applicant t
NO!'ICH TO APPLICANT':If,after making this Certificate at Exemption,you should
become s.hiacn the Worker's Comns
peation provisions of the labor Cade,you roust
O nforthwith dandy with such provisions or Ihis permit shall he deemed resulted
N
CONS'IRUC3'ION LENDING AGENCY
I her
A eby affirm that there is a compluction lending agency far the performance
of the work far which this permit i,issued Isco.3097,Civ.C 7 '
L Lender's Name
z Lender's Address -
U O 1 Certify that I have rend thea applarame and state that the a rave information is
W [�. correct.1 agree to comply with WI city and ern.my oodinunces and stem laws relating • '
U
or building mnsnation ,and hereby outhprise representatives of tones shpt.ether,upon
,rhe above-mentioned property for niss iou purposes. '
Fy �y (We)agree In save,indemnify and keep Immdess Fa City of Cnperiou arninn
rr y linhilities,judgments,costs and expensea which may In any way accrue ngaind said _ -
U .City in consequence of the granting of this penerit.APPLICANT ,
SOURCE REGULATIONSNDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
Signthavof AlareaMConalm Date Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE
W'tn are appli<aat or form handirtg tc<aPaul afare or handle hma7daa.maternaType of Roof `
as defined by the Caperton Mmactpal Cole,Chapter 9.12,and the Hwlth and Safety -
Code,Section 25532(x)?
°Ye, 11 No All roofs shall be inspected prior to any roofing material being installed.
Will tbeapoweatmfmmebtdmmg«.mpn tuseagaipnce,in desire,which If a roof is installed without first obtainingan inspection, I agree to remove
ni,hmanlnm ter cmnontmae,oe defied by the Boy At.Air QualityMnnngetnem P g
orad<t7 all new materials for inspection. Applicant understands and will comply with
°Yc` ElNo all non-point source regulations.
" 1 Ionic read the ImeuNous materials mimparrents,mmur Chapter 6.95 of the _
Calilinmia Health At Safety Code,Sessions 25505,25533 and 25534.1 melen¢md that -
if rlm building does not carrenSly have a moure,thus it is my reapomibility m madly the
cupant of the teyuir mrnts which must he net prior in isnuonce of a Certificate of
Signature of Applicant Date
Ownermttttnmraedagenr plate - All roof coverings to be Class "B"or better
OFFICE