01020084 ,j ""'CIBUo DIRTNo
BUILDING
DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESSPERMiTNO,
OWNER'S NAME: APPLICATION SUR DATE
1ONF.: - SANITARYNO, CONTROL NO.
1 C
OV5 AR CHITEC/ENGINIniR: BUILDING PERMITINFO
yy dF BLDG ELECT PLUMB MECH
6.Lu
FF66 LJ J I_] f-1
1c
lMurS DECARATION
I hent'uBiCthat Iam licensed eper oof Chapter.9 ammenct
Job Descriptiontion
sin Section oDivision n(he Busneu and Pm,.asmascot andmylicere
ag -a iin full have ad efwn.
3 ad LianseGnss Lie.1 WATER HEATER REPLACEMENT
h Uma CI SDECLAr
C ARChallHL'e use D11G1Ai,imam
S 1 Pomao,io my plans shell h nscJ m public rcrords
r
y O O Licensed Pmfcsemnal
OWNER-BUILDER m he CarATION
1 hereby.(firm that 1 1. exempt from the Cnsion,Cu License Law for the
follF Z a which ar aires a (Section)o3L5,Business and Professions Cale:Any city l county
D or
which t P n construct. he tap d f.h p y.wctam _
I rio t t til. term..nn p..11 t1 ohne Iit A II 'ga J.mtencnt
d mann i . 1p tt d p t fin I n t 1 Whot S FI. Floor Area
(Cur tgwthSut omndfuss 3thealeede dii f: scale) q' Valuation
ofS t h exertPl., f and the bu lot 1 alleged exemption.A- violamn /
of Section a than by any applicant far a permit wbkns fue upplicwt m a civil penalty
,anamoremartrise hundred dollars aslkn APN Number /Occupancy ype'
❑1.as owner of the properly,or my employees witIt%ages as their sale enmpenwtinn, '
will an the wnrk,and the structure is not intended or offered for sale(Sec.991,
ns
Busins and Pollecliors Code:Tae Contractors License I.rw m>Ls mon apply to all - squired Inspections
orndpmreny Who builds or impmvus mason,rad who does such work himself
through his awn enployces.provld,d that such impmvcmcons tie not intended or
omens far sale,u:however.the ceding or improvement is sold within one year If 502 — FINAL PLUMBING ENERGY
completion.the ownembnilder will have the burden of proproving that he did not build or 506 — GAS TEST
imve for in,x,of sale).
❑I,as owner of the propi am exclusively connecting with licensed contractors ta 507 — FINAL PLUMBING
convmct the project(Sec.7044,Business and Professions CodcU The Contractor's
License Law docs nut apply to at,('"tier of property who land or improves nhemon.
and who contracts far.such project%with it c(antmeerfs) licensed pursuant no am
Conlaulm"Liacn.ve Lam.
❑I am uacnd mole,Sea ,R&i'C lit,this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pcnalry of perjury one night fallowing declarationsido :
I have and will mrinmin it Cenilimma of Consent m selGiirre for Worker's - -
Cnlormarecof as provided hic by Seaton is
of the Lubar Coda, for rho
pnrlormtmce('f nm work for which this pcnnit is issued. '
❑1 have and will maintain Worker's Compensator brommocq m required by Seafno
37M of the I.aba Calc,for he performance of the work for which this permit is -
esued.My W'orker's Compensation Inwmnee earlier and Policy number are:
Carrier. Policy No.:
570-iriCATION OF IiXEMITION PROM WORKIAS'
COMPENSAI'io N INSURANCE '
(This section need not he cnmpdined Lose permit is for one hundred dollies
($1(0)or less.) -
I ramify that in the performance of the work for which this Permit is issued,1
,shall not employ any par Cur in any manner na as to become subject to the Worker'
Compensation laws or Crinomie,Date
Applicant .
NOTICE TO APPLICANT Ir,aft-('raking nnl,s Co mificatc al Isonptinn,you shale
Z bcmeetibiro,o me Wnt kres Compensmlan provisions of the Labor Code,you must
Zmp forthwith comply will,snch met siuns or this permit shall be derated revoked.
E CONSTRUCTION LENDING AGENCY
7 I hereby a0imrthat them is a commictinn leafing agency for the Performance ,
of the work for which this permit is issued(Stu.3047,Co,,C.1
L Lender's Na nae
z Lentlers Address -
V 1 scrod,that I Love¢rod this application and slam(hut to abovn Imonnmion is -
C entreat.I agree m comply with all city and county ordinances and sea laws elating
V w building ennamerion.and hereby authorize representatives of this city to enter upon
W the above-mentioned progeny for inspection purposes.
[� 6 (We)agree r,,save,indemnify and kerp harmless the City of Cupmnino against '
(A liabilities,judgments,reus and expenses which may in any way amore against said
C,7 sZZ City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Issued by: Date
Stgneare of Appllr nl Cnmmcue • Dom Re-roofs
IIA%ARDOUS MATHRIAI S DISCLOSURE
Will the applicant m future building snrrp.no store or bombe nmmmm mms,;a1 Type of Roof
as defined by the Cupertino Municipal Gam.Cnaprar 9.12.and The Health and Safety
Gale.Sectinn 25572(a)? -
°Ye` 11 No
'All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Lou diag(Imartmt use a(ptipnnnt or devices which If a roof is insullled'without first obtainingan inspection, agree to remove.
at baaardon-dr camun imots us retired by me Bay Area Ait Oradhy Mawgemem P
ok> oN all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 hose read the ha,int materiab,requirements under Chapter 6.95 of me
California Health&Safety Code,Sections 25505,25533 and 25531. understand man
if the huilJing does not curentiy have a mnanL that it is my reapomihili1,to notify the
rampart of the requirements which must M met prior to issuance of n Cardhicae of
Occupancy.
Signature of Applicant Date
ownernrarmnri...i ant Dane All roof coverings to be Class sB"or better
OFFICE