03020087L
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
°'' OR I1,0��-
BUILDING ADDRESS: -rtiINC
PERMIT NO,
19359 GREENWOOD DR
03020087
WNEWS NAME:
2531 GRACELAND AVE
PERMIT ISSUE DAM
'SAMUEL LOPEZ
02/21/2003
lip
NE:.(bbU)298-8494
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ip
LICENSED CONTRACTOR'S DECLARATION
JobDescrition
p
1 hereby Affirm that licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of lho Business and Professions Code. and my license is
Infall fares and off-
REPLACE WATER HEATER
Li souDate
i
&tgoclur
ARCHITECTS DECLARATION `
1 undersand my plana shall ho used As public rooms
FFF..
Licensed Professional
OWNER -BUILDER DECLARATION
i f
1 hereby affirm that 1 am exempt from that Contnmors License Lew for the
1 O
following mason. (Section 703", Business and Professions Code: Any city or county
demolish,
r
y,+
which requires a permit to construct, sugar. Improve, m repair any structure
prior to its womece.ago requices the applicant forsuch Permit to rile ulgned atakment
! a Ise 100
3<
-D
that he is Bcensed pursuant to the provisions ofthe Communes License w(ChaPlm9
[ $
(commencing with Section TODD) of Divulon3 ofthe Bualnessand Prafuslnns Cook) or
that he is exempt thconfrom and the bssla fm Um alleged exemption. Any violNan of
Occupancy Type
Section 7031.3 by any applicant frr a permit subjects the applicant As a civil penalty or
out mon than five hundred dollars ($500).
❑ I, a ower of tM pmpedy. m my employees withwags As dmir sok eompensallon,
w ildumowmk,ndmearnnunlanmmtendedmo0emdm,ale(S.c7044,Bualnea
and Professions Cade: The Controvert License Lav, does not apply k en owner of
506 - GAS T vers ns p ecnons
property who builds or improves thueoe. agM who does such work himmlf or through his
507 — FINAL PLUMBING
own employees, provided that such improvements Age rmunknded«offemd fmnle. If.
however, the building or improvement isanld within one Seer of completion, the owner -
builder will he" the burden of proving mat he did gaol build or improve for purpose of
"to.).
[D 1, As owner of toe Property am exclusively cenvaming with licensed eontncmn As
construct the project (Sts. 7044, Bustr us and Professions Code) The ConuxwwrY W-
cense Lew does not apply to an owner of property who builds ea impmvee thereon, and.
who contracts for such projects with a eontramr(s) licensed pursuant to the Contremorl
License Lsw.
[D iamexemptunder Sec .B&PCforthismuon
.me Dam
WORKER'S COMPENSATION DECLARATION
I hereby argon under penalty of perjury on of the following declarations:
1 have and will maintain a Cmiliicaw of Consent malt -insure for WmkeYaComics-
As provided fm by Section 3700 of the labor Code. for the performanm of we
work which this permit is Issued.
have And will maintain Worker's Compensatan Insurance, an required by Sutton
700 of the Labor Code. for We performance of the weak fur which this permit is Issued.
My WorkeblC—o pea%ton 1 nca canter end Policy numb/e�r'Am'
Caller. J R / ��— Poll, No.: 1.e -tea- ? A2
CERTIFI TE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This sector, greed net be completed lith permit Is foraw hummuldollars(g100)
_
or was.). ...... ____ ...
. _ _—..
I certify that In the performance of the waft for which this permit is issued, I shall not
employ anyperson In any manneran As he become subject to the Worken'Compena0ar,
Laws of Califomle. Dam
Applicant
NOTICE TO APPLICANT: IL ofwr making this Certificate of Exemption, you Mould
become subject to the Worker's Compensation provisions of the labor Carle, you mut
be deemed
OfoMwith
comply with such provisions or this permit shall maked.
CONSTRUCTION LENDING AGENCY
I hereby afOrog that them Is construction lending gency for the performance of
it
the work for which this permit Is issued (Sac, 3097, Civ. Q
Name
Lender's Addmss
ZLendm's
Q
I coolly that l love reed this application and slow that me above information Is
!!
cornet. l agree to comply with all city and county colleagues and sum laws mining w
vt�J
W
building construction. and hereby authorize repmenutim of this city to cnw upon the
.hove -mentioned property for inspection purP=L
(We) agree in save, indemnify and keep hamkss me City of Cupertino against
y
liabilltes,)udlonunm, Arens and expenses which may in any my acme agalmi aid City
In consequence or me ganikg of this Parnell
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: D x
SOURCE REGULATIONS.
Re -roofs
Signature of ApplicandConlnLSar Dow
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant scare or handle huardoue material
As defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
-
go
Me, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
[Dyes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant forum buliding occupant use equipment or devices which
mit haamous air conlominmus a final by the Bay Ara Air Quality Management
all new materials for inspection.
District]
❑Yes u
Ihavem.d the baa s makrlala requlmmmis under Charter 6.95 of the Califm.
nie ASafetycode, omions25A6,15533md25534.lundmstsndthati0e building
.y
'
11-4
does not currently have . semen. that It Is my responsibility w notl'y occupant of the
/[n
u menlswecn met armituanmancem0c, ser upaner.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner OrsuthorlAsA agent Dew