04030034 (2) CITY OF CUPERTINO ?^i3 s '""gpW'-3' Xs1Y14
BUILDING DIVISION PERMIT rCONs,TRACTxOR INFRMA' TON y,
BUILDING ADDRESS: JON R CRASE CONSTRUCTION I CMIT ND04030034
ER'S NAME: PERMIT ISSUE DATE
E: SANITARY qA*OL 030.
14 FF (4nA) 17n-14AF
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
w hereb
1 y affirm Nam at 1 licenced under provisions of Chapter 9(commencing Job Description
�iu, win Smuon )of Division 3 ofte Business and Professions Cade.and my license is
jq?<n Nfall rderke� ��d 4//:52Z7 REPLACE WATER HEATER/FURNACE/DR
License
Zt nDam__f_zYf-a_/ con r WATER SOFTENER �L �
ARCHRECI'S DEC ION
l af),dgBtAd M m my plans shall used public records
APR
PR g3 0 n O p q
oate,u _ F12004
30 t; Licensed Professional
OWNER-BUILDER DECLARATION ,
3 i F 1 hereby arrrm that 1 em exempt from rte Contractor
License Lew for the _ ffpp�I,aa.�����t M11
z 0 D following reason.(section 9031.5,Business and Professions Cak:Any city or county alb UI L D11%
m which mr,m cs a fanner io cot.alter,improve,demolish.Or repair my swcmre g tl'�7I
FIe prion,its issuence.alsu ox,mizrW applicant for such pe.i(t.file a signed statement OD
x thin he is licensed pursuant m the provisions of the Conuncur's License law(Charm,9 Sq. Ft. Floor Area Valu
ati[i}430
m (commermng with Section 7000)of Division Sof me Businev and Promasians Calc)or 7
to $ the,he is eaempt therefrom and the basks for the alleged axamption.Any violation Of
Section 7031.5 by arty applicant for a permit aubjttu thc applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars($500h
❑I,as owner o(sye property,ormycmployeu with wage ude'vmle rompewtion 36651055 . 00
will do the work.and the structure is not in¢Med or offered for age(Sec.1004,Business Required Inspections
and Professions Code:The Contractors License Law does not apply w e ns an owner of q P
property who builds or i mproves mere,n,and who does s uch work hi msel f or thmugh his
own cmplo,a s,provided Wt such improvements are not imanded orofferd forsale If.
however,Ne building or improvement is mid within one year of completion.the Owner-
builder will have the burden of proving Net he did not build or improve for purpose of
oak.).
I,as owner of Ne property,am exclusively contracting with licenced contraction to
construct Ne project(Sac.704,1,Business and professions Code:)The Contractor's Li-
came Law doo not apply to an owner of pmpeny who Wilds or improves thereon,and,
who concocts for such projects with a contrador(s)Raved purwanno the C,nuacmh
LKense Law.
l nm exempt under See. .B&P C for this mason
cr Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under Finally of perjury one of rte following declarations:
have and will maintain a Certificate of Common elf insure for Worker's Compcn-
anion,as provided for by Section 31W of me labor Code,fm the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,ss required by Section
3100 of the labor Code.for the performance of the work for which this permit is issued.
My Workers nm en stern Insunnmcame end Policy number
ma::
Cam �PoIiNFR
CERTIFIC TE OF EKF1dPr10N FROM WORKERS'
COMPENSATION INSURANCE
RTU section need not W completed if tbe Permit is foram hundred dollars(5100)
v kss)
1 certify that in thO perfomunce of the work for which this p.I,is issued,I shall not
employ any person in any manner m or to become subject m the Workers'Compensation
Laws of Califomia Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenibcam of Exemption,you should
become subject to Ne Worker'a ComPeruation provisions of me Labor Code,you mnsr '
.J O fothwiN comply with such provisions or Nu Permit shall be deemed revoked.
z '"" CONSTRUCTION LENDING AGENCY
p'4 l hereby aRrm Nat Nem is a consuemm lending agency or me Performance of
D: > the work for which this permit 4 issued(Sec.3091,Ci,C.)
Wo Lender's Name
z Lender's Add.,
U 0 I certify that 1 have mad this Vpliation and sum,Nat Ne above information is
W E' Correa I agree to comply with all city and county ordinances and state laws mining b
0U building concoction,and hereby aumodm repmsenutivas of Nis city m enter upon me
W above-mentioned property for inspection purposes.
G (We)agree or save,indemnify and keep harmkss one City Of Cupertino against �S
Tn liabilities,judgment.costs and expenses which may in my my same against said City /
U z APPLICANTOof UNDO grmung of this
NO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER TI
E X Y--0 r Re-roofs
p c HAZARDCOUS MATERIALS DISCLOSURtor E ate Type of Roof
Will Ne applicant of future Wilding Occupant atom or handle hazardous material
az defined by the Cupertino Municipal Cade.Chapter 9.13,and the Hcalth and Safety
c,section 15533(¢)?
❑Yes �Nu All roofs shall be inspected prior to any roofing material being installed.
Will rte applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t ha>an oars or mmumorismin as dcfred by the Bay Arca Air Quality Management all new materials for inspection.
Dinrin?
❑Yer
I have real the hvanlous mau oisrequiremenu under Chafer 6.95 of the Califor-
niaHcalN&Safety Cock,Sections 25505.25533 and 25534.1 understood Nm ifthe Wilding
dos Out currently have a enact that it is my responsibility in entity use,ecupant of the
requirements which pnormiamanee aflQ 'eaOceupancy. Signature of Applicant Date
T— sea
Ownmn.dagent Date All roof coverings to be Class"B" or better