03010118CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
WATER HEATERS ONLY
PERMIT NO.
830 HOOSHANG CT
nimoilp
OWNER'S NAME:
970 E. MAIN ST, SUITE 200
APPLICATION SUB DATE
KENT DAVID P
01/22/2003
ONE:
(415) 566-2209
SAN)PARY NO. CONTROL NO.
ARCHITEC BNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
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LICENSED CONTRACTOR DECLARATION
I hereby off. the, I am licensed under prnv,smoo, of Chapter 9lcnmmencing
Job Description
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with Section 7faaB of DivirinnJnf NC Business and PrnfcssionSCode, antl myl¢cnm is
infall force and ef ea tf
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REPLACE WATER HEATER. �`Q����®
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Idem CI�.a
oafc /O3 Conva<I'
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ARCHITECTS,hall DECLARATION
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I understand mY plane hall M used as public rttnrJS
FEB 2 0 2003
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Licensed Pnrlcssiunal
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OWNER -BUILDER DECLARATION
RATION
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I hereby .farm Inas 11. eaempl he the
me ContrnsCoo Liceme Law
BUILDING
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reason. (Section ID3I.A Baalnaa andProcessionsco
ao clove: Any city orructure
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whichcfollowing
improve. d
demolish.
which requires a perosl re umsmthe alter, improve, demolish. m repair any Mortem
tritonslicensedts pursuant requires thovisio so for mchpctor a c) file aLicense aw(Chtemem
that hcisliccnudSectionlMpmvivision3 M1c
Sq. FL Floor Area q�f pion
$
ficchat he is exe with Section ]land) Division 3 eBusinnrsndProclaw(Chapmr9
the Business and Cole) or
thus he is thcmfmm Ne basis for the
exempt and the the on. Any
alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
be
Occupancy Type
not more Nan five hundred dollars (SSm).
❑ I, as owner of lie property. or my employees with wages as their role compensation,
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will do Ne work, and the structure: is not intended or offered for We (See. 7044, Business
—
30T ROUGH B G
and Professions Code: The Contractor's License law docs not apply to an owner of
303 - ROUGH acLlons
property who builds or improves themon. and who doesxuch work himself or through his
provided Nat such imprm:mcnta are not intended or offered for sale, If,
304 — ROUGH ELECTRICAL
hwemployers,
ewr, the building or improvement is sold within one year of completion.
proving Nal he did not build or improve for purpose of
505 - FINAL ELECTRICAL
salk,1
507 — FINAL PLUMBING
❑ L as owner of dire Pmpcny. am eaclusivcly contracting with licensed contractors to
construct theBusiness and Project (Sec. 7044. Busineand professions Code:) The Commences Li-
508 - FINAL MECHANICAL
u taw does not apply to an owner of property who Wilds or improves thereon, and
who connotes; for such projects with a contractors) licensed pursuant o the Cnmracmr's
License Law.
El am carrot under Sec. ,B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
41
I hereby affirm under penalty of perjury one of Nc following declarations:
orker sCumpcn-
0 I ban and will maintain a Cenifrcmc of Consent to selGinsum for Worker's Com,cn-
cation,
cation, m provided for by suction 370() of the labor Code, for the performance of the
work (m which this peoril is issued,
have and will maintain Worker's Compensation Insurance, as required by Scomn
Irl of the Labor Code, for the performance (if the work for which this permit is issued.
yWororr'aC pcnsa0. I"..nee carrier and Policy number am:
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Canicr,�� Polity
CERTIEI ATE OF E%EMPToli FROM WORKERS'
RO WORKER
COMP17NSATION INSURANCE
This section need not M completed if tM permit is fortune handled dolars 1911)(1)
n Icss.)
I cenify that in the Performance of the work for which this permit is issued. I adult not
employ any person in any manner at, as to Mcnme sohject to the Workers' Compensation
Laws of California. Date
Apron,
NOTICE TO APPLICANT: If, after making this Cc, ilicatc of Exemption, you should
become subject to the Worker a Compensation provisions of the Labor Code. you must
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comply with such provisions or this permit shal l M deemed revoked,
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CONSTRUCTION LENDING AOF,NCY
I hereby affirm Nat there is a construction lending agency for the Performance of
the wink for which this permit is issued (Sec. 3I97, Co, C)
Q1<ndcr's
Name
Levulan Address
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I certify that I haw read this application and Stale that the above information is
Fcorrect,
l agree to comply with all city and county ordinances and state laws relating to
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building construction. and hereby anthorive rcpresemmives of this city to enter uptm the
above-mentioned property for inspection
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purposes.
(We) agree hf save, indemnify and keep harmless the City of Cupertino against
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liabilities, judgments, costs and expenses which may in any way acerae against said City
in consequence of the granting (if his permit,
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON. INT
SOURCE RCGULATIW
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e"
Issued by: Dale
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Re -roofs
Signalurc of ApplicanVComracmr Dale
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will dIe applicant of future building nccupanl store or handle hazardous material
as defined by the CuPeni no Municipal Code. Chapter 9. 12, and me Health and Safety
elate, SccOon zss3zlan _
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All roofs shall be inspected prior to any roofing material being installed.
win thea scam m more building occtu equipment
Pn I. pans sae a ent of devices whim
If a roof is installed without first obtaining an inspection, I agree to remove
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Fort hvamous to contaminants or Jcfincd by the Bay Arca Air Qualify Management
Uianicl'r
all new materials for inspection.
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1 havc read the WraNnus materials rcyuimmcnu under Chapter fi 95 of the Califnr-
& SWMy Cock. ScNorSs crsfarN Wl ifthe building
d 255Jity
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dms nano
at it i, res
Jnea non curtendac M1asc a mumu prat it is my reslxinnihility In nobly the ¢c p I of
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rcyuimm ac ust Mmcs poo anccofa CcniOcn¢nf 0.cyp y.
Signature of Applicant Dale
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All roof coverings to be Class "B" or better
OwncrolauNofimd gent z Dafe