03010177 CITY OF CUPERTINO ''- "-
BUILDING DIVISION PERMIT CONTRACTOR INFURMATION: ''..
BUILDING ADDRESS: HOT WATER INC PERMIT NO.
21060 HAZELBROOK DR 03010177
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
DAVID COOPER 01/28/2003
"E (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECOENGINEER: BUILDING PERMIT INFO
BLDG ELECT 'PLUMB MECH
0 0 0 0
Op LICENSED CONTRACTOR'S DECLARATION ,I b Job Description
�zj F I hereby a(Brm Nat I am licensed under provisions of Chapter 9 an fee sr 1 na P
�z4 wI %ndl.ndc.
f Divisinn3nf Ne Busines Professions Cabe.and myliccnsc is I^
<6 innme did (�l2 R ��EATER HEAT
ZO LiL1c.Nr f t
KmI-p DawCnntrqq,� ARCHITECTS D'f 2 y plans sM1all be used as Puhlic rccnNs
%�WaV
w a C
Licensed Pmfcssinnal
-3+ OWNER-BUILDER DECLARATION -t
1 hereby.(firm that 11. exempt from the Contractor's License Law for the
m—p O following mason permit
t ]onstr Business and Professions Code:Any city or roomy
which its s issuance.also re quires me,altee improve,demolish,or mash any structure
prinrwslicersed int lnation the thcisiorm.ntfor such permiunfmusele a aw(ned stammem
t?x� (cothe menccensedpursuant to the provisions of theeBusines snd Prof LawlC mm)or Sq. Ft.Floor Area y�`$aDl(,1tlOn
F$
(commencing exempth Section 7")of basis
rth al Business end Professions COJc)of
.. Net he is exempt therefrom and dm bazis for the alleged exemption.Any vitiation of
Section 7031.5 by any applicant for a permit subjects Ne applicant o a civil penalty of 3a Occupancy Type
not mom than five hundred dollars($5110).
C 1,art owner ofthe properly.or my employees with wages as their able compensation,
will do Ne work,and the suucture is not immndetl oroffemd for in(SecAM4,Business
and Professions Code:The Contractors License Law does not apply to an owner of 506 - GAS TE ggU1Te spec Ions
Finnerty who builds or improves thereon,and who doer such work himself or through his
own employees,provided that such improvements ere not intended or offered for sale.If, 507 — FINAL PLUMBING
however.Ne Wilding or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
C 1,as owner of the property,am exclusively contacting with licensed contraclom to
convect the project(Sec.76X,Business and Professions Code:)The Contractors Li.
cense Law does not apply to an owner of progeny who builds or improver thereon,and,
who contracts for such projects with a comrachods)licensed pursuant to the Contractors
License Law.
C I am exempt under Sea ,B&PCformismarron
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby of bin under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Camped.
salon,as provided for by Section 3'703 of the Lahore Code,for the Performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance as required by Section
37(Xlofha Lmmo Cmk,fnrdeperformance Ne work for which thispermit is issued.
Myers n pen cion In once can Polity boons 1.
r Po W
ERTIFIC TE OFOMPE $ATIXEM INSURANCE WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the Permit is fbroac hundred dollars uUX))
to[as.,.)
1 certify that in the performance of the work for which this permit is issued.I about not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
became subject to the Worker's Compcare ion provisions of the Labor Cum,you must
OO forthwith comply with such provisions or this permit shall M doemed mvokcd.
zCONSTRUCTION LENDING AGENCY
aiE M1N-t Ihereby.than that dere is a consuccion lending agency lin the Performance of
Pthe work for which this permit is issued(Sec.3017.CO.C.)
W� Q Lender's Namc
z Lender's Address
U O I certify Nat I have read this application and sum that the above information is
IL H cortin.l agree to comply with all city and county ordinances and state laws relating N
Q V building construction,and hereby suthbrim representatives of this city to enter upon the
LLl ahove-mentioned property for inspection purposes.
L}.t, (We)agree to save,indemnify and keep harmless the City of Cupenino against
r;y pj liabilities,judgments,costs and expenses which may in any way accrue against to City
U 7 in consequence of the granting of this Permit. _
t� APPL UNDERSTANDS AND WILL COMPLY WITH ALL ON-P INT Issued by: Date
SOU C ULATIONS.
si dipvrAPNicanucomractor Da
Re-roofs
HAZARDOUS MATERIALS DISCLO URE Type Of ROOF
Will the applicant or future building occupant store or handle haarmhow material
as ecBnee by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
rbc,Section 25532(x)? (�� All roofs shall be inspected prior to an roofing material being Installed.
❑Yea % . P P Y g g
Will the applicant ar future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict? ��)
❑Yea C13d,
I have read the hamolous materials requirements under Chapwrb 95 of the Califon
ole HcnlN&Safety Qbc,Sections 25N15.25533 onU 25534.1 unecremnU NazlfNc hull ng
dove note.rtcntiyh.veawnant,Natitismyrespnsihilitywnoulythcacu totc
require evwhichmust Mmet poor toissuance ofaCcnifcateii c c. Signature of Applicant Date
Owner nr aulhoriveJ agent ret All roof coverings to be Class "B"or better