01030010 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
0 1 Die
• ,
OWNER'S NAME: APPLICATION SUB DATE.
NOSE MQRTIN 14 El QI 17E4 NAITONAI 1
'PHONE - SANITARY NO, CONTROL NO.
0) P92-9991i
C2 ARCHITEMIENGINEHR:
(WILDING PERMIT INFO
O O BLDG ELECT PLUMB MECH
6
5' ucervsrncoNTRncrDRSDEc1.nlxnnOry Job Description
ZIn by dfnn Intl nfence d P s of Cnlpter 9(tnmmeming
o z—°w welt f 7000)its Mi 3 nbe nn : d 1 t .es
mm enea a nl my billowz Y f 7is in 1.11 tome and effect
eeza Fie : CIs « REPALCE 50 GALLON GAS WATER HEATER
O e.U Dee Comnemr
3
F' ARCHI'I FC F'S DECLARATION
t a O1 understand my plamu
ns ll be used as public records
sit a p O Licensed Professional'
OWNER-BUILDER DIiCLARAT'ION
1 hatehy.(lino that 1 1 esempl from the Cblttmelnf s License Law for the
C Z 6 fobuls om aada ire,a(Scnian 7n3LS 9.aler.s.W Ive,brandish,
Cods:Any city mcaumy '
I`❑ which requires die,also to requires
aline nt(ora demolish,nr repair nny ttmaure
rc' Is:,,
ohe its ds"dsi,'Iso rcgnild the proves iso for Coludiuch miuufeeasigaN statement
�3m
(commencing
is titan wit Pmmion"laprnms"idamnhcae Ints,mrsLice me Lassions "erg Sq.FL Floor Area � Vat ion'
(ehmmomis exempt
s and
vision 3 rt the Bmines mpown.Any
sessions Calci
or Ine he 7 31.5 h therefrom and the basis Bit the ts,'halleged cxcmpu t In nny l striation e
of no(more
7W l s iv mu hundred
d ll fnr a pcnnil sunjans'he uPPlicunnn n civil penulry
of urn more matt five hhtneree nauara aswl. APN Number c ((Icy pe
D Las owner ohne Property,or my employees with wages as Amir sole cmniskmation. – _
will on the work,unit the svacmre is not intended o,ofteed for sole(Sec.W94, Ike aired Inspections
"Business and Nnfession,Cat The Commanr's Liceme law does not apply to an 9 P
owner of property Who buildsnr Improves thercnn,one who does,such work himulf
or though his ow it employee,,pn,vdW that such improvements am not intededor 502 — FINAL PLUMBING ENERGY
offeree for sale.If,however the building or improvement is sold within ane year of
completion.the awnerbuilder will have the budded of proving that he did urn build or 506 — GAS TEST s
mpr ..ve f..pomosr of sldc).
❑L as owner of she property,. exclusively comraning wish licensed contractors to 507 — FINAL PLUMBING
omtract the project(Site.9(94,"Business nod Professions Cudep The Councillor's
License law elan not apply rah on owner of property who builds or improves(hereon,
mad who commits for such projects with a commcan6)licensed is....a,m the
Cman con's License law.
111 ant.worst ruse,Sec. .11&P C till this rano
Owner Orae
WORKER'S Cl lhl...?NSNDON DECLARATION
I hemby affirm under Penalty of perjury one of the following declarations:
•'D I have and will muinwln a Cenilicate of Cometh to sell-Insure far Worker's
Compensation, as provided for by Section 37W of the labor CWe, for the
perfunnnnce of the work for which this peril is issued. ,
01 have and will maintain W'orker's Compensation Insurance,as required by Section
1700 of Inc lather Code,for Inc performance of the wo,Is lot which this permit is
lolled.My Workers Crnnpen alkad Insuome,currier and Policy raft:(dire:
Carrier: Policy Nn.:
cuin nicsPION OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE -
This seeder need nut be completed if list peril is for one hundred Jolltus
($IlNf or less) '
1 certify that in the Performance of the work for which this permit is issued,1
nh.11 not employ any harson in any manner wt into hcenmc subject n the W..co,
Compensation laws of Calirontis.Date
npplic.ns ,
NOTICE TO APPLICANT.If lie making this Crnilicme of)!sun innion,you should
Q Obecame subject the Worker's Copasotion provisions of the Labor Code,you must
ttmforthwith comply with such provisions or this permit shall he deemed revokes.
z
F y
CONSTRUCTION LENDING AGENCY
a > (hereby affirm the Ihni iss roued(Set. 1W7. agency far the perforance
F>a rf the work fnr which this Permir is,.sued ISn.Jo97,Civ,C.)
0. Q Lender's Node
;D z Lender's AJdrcss
V C ' 1 cortify thin I dive rend this uppllculion and num thanhe almvcinnnmminn Is '
V. P comet.I agree m comply with all city and countynuisances and slate laws leasing
r..I to huiWing construction,and hemby immunize repm%cnlatives of this city m enter upon _
H
0c'novo. amiousel pnmedy rot om"',ion pnrp...es.
Cis edn
(Wits agree to save,indemnity unit keep harlexs the City of Cupertino against '
V) liabilities,judgments,cusp and expenses which may in any way.croute against said
U City in conwgacnec of the grmling of his permit a .
APPLICANT UNDERSTANDS AND WILL COMPLY WRIT ALL NON-POINT' Issued by: Date
SOURCE REGULATIONS.
Slgnateeof nppfcatnrcontrnem Date Re-roofs .
IMARIMUS MATERIALS DISCLOSURE - -
Wllthcapdicam-future holding umulimsand onhostile hvaNnmmaterial Type of Roof
as dcfned by the Copcninn Municipal Code,Cdeprer 212,and the Health ane Smey '
Code,Section 255321.1^
Dyes 0 N All roofs shall be inspected prior to any.roofing material being installed.
Will upplicam or lmure building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
,.is hnz.Nous tit,com mono is as defined by the Bay Area Air Quality Management
District? - .all new materials for inspection, Applicant understands and will comply with
0 Y odd
all non-point source regulations.
I have rend the hazanlous antitrust,requ Remems.unde Chapter 6.95 of the "
Cuilbrnia l icallh&Sufey Gxlc,Sucduro'25505,255J3 and 25534.1 uneestand shot '
if the building docs non currently have a tenant that it is my responsibility to notify she -
panl of the requirements which must be uta prior m i...ance of a Centipede of
Oraro'diney Signature of Applicant Date
Owner or ndtorized agent Date_ All roof coverings,to be Class "B"or better
OFFICE