02090155 ;CITY OF�CUPERTINO.. ..
e7ntotNcntvtstor PERMIT CONTRACTOR INFORMATION:
9d-` 'tAnAY DR WATER HEATERS ONLY PER TY090155
sl5tMHIHARI 70 E. MAIN ST, SUITE 200 APPL MgIpIn02
PHONE: (415) 566-2209 SANITARY NO. CONTROL NO.
r9 Q ZO
ARCHITECT/ENGINEER: 4 - '--_.. BUILDING PERMIT INFO
kC�u rte , BLDG ELECT PLUMB MECH
�,',� LICENSED CONTRACTOR'S DECLARATION �tT ( ' I �' r
0 Z4 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing LA(.'r+, In1AT ,R',H tlOn
F'r3 wihsec11on 7000)of Division 3 of the Business and Professions Code.and my license {y
nfull farce andAfiect�L I I
LLiilrgas�� vv L¢ Y
.7 ¢ .Date '1/P� Conlranor �A /
F,IY so g ,' �',1 understand my plan that bCH e med as pad,E r.
O O .;Licensed Profemional
OWNER.BUILDER DECLARATION
1 hertby afOmi that 1 am exempt from the Contracmr's License law for she $700
C.z< .following remora(Section 7031.5.Business and Professions Cade:Any city or county
O which requires a permit to construct,alter,improve,demolish,or repair any structure
3$.prim to its issuance,tlso requires the aptyicwi(or such permit w fil...gnsonetemem
.the ii littrju4 purryuri(m 'prbvhiOns of the Conrnu'rors Littnse law(Chager9 0 ea Valuation
Y(comrneoaingwMSw4m7 )of DivisionJof rhe Busineu eM Prpfe}sions Cade) (..(1."x'_ q{.—a•., 2iySl E_el y,4;Pl�'�t �'�t�'Y •
or thai he It ekempi Nemfrh h'and the basis for the ellegetl'eAempiCn.Any violation
of Bdnion-7011-.5 by any-applicant for o permit subj"rhe applicant to is civil penally'
of not mote than B.hundred dollars($51)(1), 3U5 RP e tiara^:q• Occupancy Type
01,as owner of the property.or my employees with wages m their'sole compensation, 307 - INSULATION
..ill do the'work,'and-the'smooth,Is act mandtEor offered'for sale(See 701
Bbsiness and Professions Cade:The Contractor's License Law does not apply toweCtldtl$ ^`
awncr of property Who builds or improves thereon,and who does such work himself 602 - ROOF PLY kinfi a
r thtou h his own employees.provided Nat such improvements wo not intended or _ _+
R icd - I .-If-'h th building onmprovcmet 1a withinone year of '603""---"'"ROOF- BATT "
'ENS ' ,;, r .,-•rn ;
k
odrinpletuan,the owne budder will hevethe burden ofproving that hedid not Wild or 604 - ROOF IN-PROGRESS '
Improve for purpose o(mle.).
.,__... _.,. ,..iiia__,.. , ,_....-..."_iiia . ......____....
pd mpwher pf the propertyam Bus weltcommctingwith W.:) do C.nl mnro
conswn the dopro,es
no(Sec.7044,Business and cry,who
Cade:)The Ca thereon,
who
Law dors not apply to Ian owner th property,who builds su improves Lhertan,
.-.ad.who co Licca for such prof cu sth a conlmciurlsl IcemrG pursuant to-the. ___. .._.. ... iiia--------
Contractors tLicenselaw.
❑ mPt
5 , 1 m<xept under Sw Ir � _ ` _ BI&PCfor thu remora
Owner, '- r.Date
WORKERS COMPENSATION DECLARATION
U' 1 hereby aRrtm undm,j Ityidfperjiay ane of the fall,dalamuons ` Q
I'heve aiid odt'maimlam o Cmificxm'of 6.;..t Po xlf-iruum far Worker's J� v
.;Compent iom, m.proded vifor by-Sa1m.-3700 of the Latin Cade, for the _\
peifomiance'of Ne woh for which,this Pe tis is wed.
�L�rl�by a and will r Crntdm Worker e C mpcnwi on e'woace,m Lrymrcd by Sahara
Y160 oMHe'labur Code For Lhe performance of the work for which this permit is
tamed My Wor s amp miation oro a comet tad P I ry number ere
p r
�� I "CERT M'ATION'OF PXEMPTION FREC1,We— RKERF'�' n 4 C'i,•e
rnnrr-n..^».mCOMPEN5AT10N INSURANCE; -
^ iThla rediidn need io(be completed if the permit is for one hundred dollars i h' ~
151 W1 nr,end
' f I cera fy that In 1h!pert mance al the work'for which this Perm t is i v°d- 1 -
shall int a iploy'liny person in any manner so as to become subject m the Workers
Compincitiun'Laws of California.Date
Applicant. .,
14MICF TO AP LICANT.If alter m kmg this Cen fic to f E mpdoa,you shmld
. become sobjecuo the Worker C mpensaunn pro ons fth Lahbr Code,you most
rQr7-� O forthwith comply woh sbch provisions.,,his permit shall be deemed revoked.
CONSTRUCTIONLENDINGAGENCY
6fthe reaR Lh r rhe a is co t Sten Iendinj;agency for the performantt _ .i
work farar which rho pemmt W'Q iss MIS.. Civ C)Lerder•a Name -� "`.•..`_......_ ....
a° Lend rsAddress - -
I certify that I howeirol thus.,licatimt.od.anothwhothove information is
W• lime1.1 agree rocomply who all city said county ordinances and state laws relating
as
IJing construction,and hereby atuatorrizo ropm,emmiwi, f(his coy to eater upon
the abovemeplioned property for inspection purposes.., ,
p,'' (We)bgrtet s ve Indemnify end Aeep harMess lheC tyofC pens o gvinst
Fr'V]` "a"
jgdgmeats c ns and,expo h h may jn any ay acme egmnn said
V Z Cu n consequence of th gr min of shit peon t - _
n"t- AP LICANT UN'pER$TAN¢q. , LL COhIPIT WITH AiL o' oI' Date
SO RCE 1iEout.Arin � car; Issued by.
Its
mrepfApplm nrK mrdcror Re-roofs
' I HA2ARDO MATERIAfS DISCLOSVRE
pp g p Type of Roof.. _............. ._ .
Wll thea licvnr orf to nuildm rccu ant sr re orh dl hazmdo meted
• s d Bned M1y th Cupertino Munlc pal Cad Chapter 9 12 and the Health orad Safety
..Cale.Semlon 2333(1 a
.. All Toofs.shall be inspected prior.to.any roofing.material being installed._...-
Will the applicant r future building occupant ueeeq p rchni e.which ' If a roof is installed,without first obtaining an�inspection I agree to ieinove
emit iuizardoms air contaminants as defined by fire Bay Arta Air Quality Management
District! all new materials for inspection..,Applicant understands and will comply with
❑Ya v , �n+
;.,, all non-point source regulations.` ,
1 fiave read the haivdous materials requirements under Chapter"3.of the
California Health&Safety Cale,Sectlom 25505,5533 and 25534,1 understand that _
if the holding draw not currently have o lemnt:that it is an,responsibility to notify the
Ceensof the rtqui ents which i be mei prior m iswwce of o enific ni,of '
�1 d Signature of Applicant _ .__ - _ _ - Date _
�• .:t Owner or am sed.&ntDate. All roof coverings to be Class`B"or better
,I
..r iiia.. "'•.nr..-.N,t. " ..:.' ...�. °iiia_ :.iiia '..r- .iiia
r_ ,... -OFFICE----....._....