00100095 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDINOADDRESS SHILES JUST WATER HEATERSPITTD00100095
OWNER'S NAME: APPLICATION SU D''
10699 GASCOIGNE DR. 1764 NRTIONRL AVE ). 12/2000
ZONE: SANITARY NO. CONTROL NO.
(510)293-9901
O ARCHITF:CTIIiNGINIiIiR'. BUILDING PERMIT INFO
y m BLDG ELECT PLUMB Mr:CH
Z O w y LICENSED CONTRACTOR'S DECLARATION 106 Description
_I I hereby aRnn mm 1 am licenced under provisions d Chapter 9(rommcncmg
O
with semion]axRona"isinner,fineawsmexaand Pmre..innsCode.and mybeenw
is in fall farce and effect.
REPLACE 40 GALLON GAS WATER HEATER
ce S
r,o ai License eluss Lic.N
Dae Commetor .
ib n. ARCHITITUI'S DIiCLARA'I'ION
1616 O 1 undemmd� my plans shall M uwd ax public record,
is
i p C Licensed Pmfessional
n' OWNER-
BUILDER DECLARATION O
u1= 1 hereby affirm that 1 am exempt form the comment',License Law for the r
tl 3< following reuwn.(Section 7031.5,Redness and Professions Code:Any city or county '
fr'd❑ which requires a permit m cnmtrml,alter,improve,denioh h,or repair any structure
iia$ prior m islssounce,also reyuirexlhc uphlirant tort such perntinu file a signed statement
Ilmt he is licensed pncvuard Inthe It Loons of the Conmmior's License Law(Chapter 9 Sq, Ft, Floor Area at1O
(commencing with Section 7000)of Drvldon 3 of the Bndnes,and Itmfi Worts Co,c) 625
or that he is exempt therefrom and the basis Int the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the appueam m a civil penally Occupancy Type
of not more man five handled dollars($500). APN Number
❑1,as owner of the pro,sth,.Or My eiiployee.with wages as mcir,ale compitmor on, 3753101.7. 00 '
will do the work unit the nuctme Ix nm Intended or uttered far sale(See 91)44,
Dashes,and Knre,sions Code he C...mtc or's Licmne Law dem not apply mi all ` Req Hired Inspections '
riinclot property Who builds or improves thereon,and who does such work hlmselr 50t_ — FINAL PLUMBING ENERGY
a,through bis own employees.provided Thal such improvements ere not intended or _
offered fonale.If,however,the building or improvement is sold within one yea of 506 — GAS TEST
completion.the ownerhuilder will have the burden of proving that he did not Wild or
opm.ernrpmTO,cof,r1c.). 507 — FINAL PLUMBING
01,as herof the nopony,not exclaslvely contracting with licensed contractors"
immum[lie projeo(Sec 7044,Hooness and Prefessions Code:)The Contractor's
License Law do,,oil apply nun owner of property who builds or iniprnves thereon,
and who contracts for inch projects with a contmetorls)licensed pursuant In the
Contractor's license LoW
❑1 am exempt under Sec. ,11&P C for this reason
Owner Dae
WORKER'S COMPENSATLON DECLARATION
1 herehy nlfirm under penally Of patury tine of Inllowing declaration%: ,
t7 1 have and will notional,a Crailicule of Consent to self-insure 6i Worker's
Compensation, as provided An by Section 3700 of the Luther Code, for the
performance of the work fnr which This permil is issued,
❑I have and will maintain Worker's Compensation insurance,as required by Section
391,5 of the Lathan Court for the perlunnunee of the work for which IM1is.permit it _
stied.My Worker's Cnntperoatinn Insurance Warier and Policy mnndor are
Carrier: Policy Na:
C12RI IPICATION OF LXEMI•TION FROM WORKERS'
COMPENSATION INSURANCE
(This section need or be completed if the pernit is fnr otic hundred dollars
(SIM)or less.) i
I certify That in the performance of the work for which this perm0 is issued,I
shall not employ any person in any;nammr x)as ui hecona subject to the Workers'
Conipenmtin i Law,of Culifornlo.Date s
Appllcam
NOTICE TO APPLICANT.If,after roukingthis Cerificaeol'Ficemption,you should ,
0 O become oe subject to the Wmkee,Compensation prons visioof ine Labor Code,you nim.
fen ovim comply with such pirmyWonv,r this permit shut]R deemed revoked.
F CONSTRUCTION LENDING AGENCY '
�i1 hereby nllirm Ilial them is a cmntinaion lending agency for the perfomxaice
of(he work far which Thi,pemtil is issued(Sec.3097.Civ.C.)
11 Q LmNcr',Name
7 Lender's Addmss
U0 1 eanify that I have read this applicmion aM stere ohm the grove information is '
Ear crnKl.1 agate ni comply with all city and county ordinances and state laws relating
0 U to building construction.and hereby authorize representatives ofthis city to enter upon
fey the d ood-o emiorwd pmpeny for inspection patpows.
Ey 6t (We)Other grave,Indemnify and keep harmless the City tit Cupenino agents
UZ) liabilities,judgaa.•nll,costs and expanses which may in any way aecmc agaimt said
� City in consequence of the pmoling or this peril(.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT db
SOURCE REGULATIONS. ]SSHey. Date
Signature of ApplicanVContmetor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant it,future building aesupata pore or handle haeardops meren.1 Type of Roof
as defined by the Cupenlno Municipal Cixlc,Chapter 9.12,and the Health and Safety
Coda Section 25532()41
❑Ye, 0 N All roofs shall be inspected prior to any roofing material being installed.'
Will the applicant o.fumrcbaddmguccupantuse egaipm,mOrdesse,WOich If a roof is installed without first obtaining an inspection, I agree to remove
iii hazvdous air contaminants as defined by the Bay Arcs Air Quality Maiugement
sic'? oN all new materials for inspection. Applicant understands and will comply with
0 yes all non-point source regulations.
1 hate reed 0¢harardnus nwmrinls mquirenncros under Chapter 695 of he
California He;Illh k Snfay Code,Sections 25505,25533 and 25,5;14.1 undcrsmnd that ,
it the building Jocx nm curzemly base mmoumnhm it is my rexponsihilitymnntlfy the s
orifi,and of the rcyuircnroms which nest he met prior u,issmnm of a Certificate of
Occupancy. Signature of Applicant Date
Owmmot aborted agent Date All roof coverings to be Class "B" or better
OFFICE