03030035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC�TQRINk'ORMt1TION Vis.
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.
91 9 KIM RT
OWNER'S NAME: 970 E. MAIN ST, SUITE 200 PERMIT LS A
NE: (800) 835-5946 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j00 LICENSED CONTRACTOR'S DECLARATION O O O O
�C Ibcrcbyaffirm[let l am licensed under previsions of Chapter 9(Commencing Job Description
!�E with Section 70fD)o(Oivision3ofthe Business and Pmfesdom Code.and my license is ym� � ,aa r5 ��
n in full for¢end effect. F f k L
? License Cl Lica 3t Sly REPLACE WATER HEATER
Data Co irseYof y�r� ']
ARCHITECTS use DECLARATION MAR 2 a� 2003
1 understand my plans shall W used a public Ameards;rION I
c G N Licensed Prefessum al
s OWNER-BUILDER DECLARATION BUILDING
% i hereby affirm that 1 em exempt from tim Comramoren
s License Law for IW
a O following mason.(Section 7031.5,Business and Pndessinos Code:Any city or county
5 S� which mimims a permit On cnrmrmt.elect.improve,demolish,or repair any structure
prior In its isauanco,also requires the applicant for such permit to file a signed statement
� that he is licensed Formal in the provision of the Co ucheidri Um=Law(chapter 9 Sq.Ft. Floor Area I��ion
(commencing with Section 7")of Division 3 of the Bushman,and Professions Cade)or
'F1 Nal he is exempt Netcfmm and the basis for IW alleged exemption.Any violation of
Schon 7031.5 by any applicant for a permit subjects the applicants o a civil penalty of
not mom man fin hundred dollars($500). 3 db9193ef 0 0 Occupancy Type
1,as owner of the property.or my employees with wages a their¢ole compensation, .
will do Me work.and lheswclum is not intended or offend for ate(Sec.7061,Bumnaut 502 - FINAL
and Professions Code:The Convactne,License Law shoo not apply to an owner of cdWk'RGY
property who buildsorimprons thereon.and who doessauchwmkhimulfor through his 506 - GAS TES
own employees,provided that such Improvements are not lmmfided oroRered tweak.If, SO7 — FINAL PLUMING
howewn me building or improvement is sold within one year of completion,the owner-
builds will haw the burden of proving that he did not build in Impron for purpose of
ole.).
❑1,as vwnr of me pmpeny,em exclusively contracting wish licensed conaacton to
convect the pmject(Sec.7014,9niness and Profession Code:)The Conirumri Li-
arrace IAw,does not apply in an owner of property who Wilds or improves Merton,and
who convects for such projects with a contractor(s)licensed pumant to the Cuntnctor's
License law.
Olamaemplum Sec. ,B&PCforthismamn
Owner Data
77MWORKERS COMPENSATION DECLARATION
1 hereby sf na under penalty of perjury arm of Me following declaration:
hew and will maintain a Certificate of Consent to selfdnsu ,for WorkeriCompen-
n,as provided for by Section 37011 of Me labor Code,for she pctformena of the
for which this permit is issued,
haw and will mountain Wallace,C unpmWllan InNMR,an mgalmd by SCLtion
of Me labor Code,for Me performance of Me work for which this Permit is issued
Warkch Com axUX-mN�.mociend Policy nmW�+r art: Zler: LXTJJr rl1' I` Policy NO:I Ga SV 3-0Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7Tlsuctlon need not W eomplemd if tse penult Isfmonc hundred dollen(SIM)
nr les,)
—'—"' 1 certify that in the perfaonanec of Me work for which this permit u issued.I shall not
Lata California any manocrsnas Mbocome abject lathe Worked Campew0on
Lowe of California.
Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subjocl m the Worker's Compensation provisions of the labor Code,you muse
Dp forthwith comply with such pm,isi......his lermilshill be dcamcd revoked.
Z Vy CONSTRUCTION LENDING AGENCY _
I hereby affirm Mat Me"is•convection lending agency for the performance of
Y, Me work for which this permit is issued(Sec.3097,Co.C.)
A4ndcr's Name
31 Leader'.Address
;J Q 1 certify Mall have reed this application and sum Mat he aWn InformNon Is
7. (~ contact.I agree to comply with ell city and county ordinance,and state laws relating to
V building consWCGon.and hereby authorlm npmsenlalins of this city to enter upon the
W aWve-mendotmd Propcnyfor i 'fy purposes,
agree m ave,indemnify and keep bermleas Me City of Cupertino against /
fq liabilities.Judgments.costs and expense which may in anywayacrnmagainl aid City /C
Jz in consequence of the granting of this Permit.
APPLICANT r SOURCE REGULATIONS NDS AND LL COMP WITH ALL N N-P INT Issued by: Date
2E 6 Old Re-roofs
Sgature of AppucmuC.otrsectm Data
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
Will Mee,Cupertino
or future building occupant atom or handle busman dSafrinternal
as debned by the Cupertino Municipal Code.GMpecf 9.13,and Me Health and Safety
Cade,Seabee 25532(a)?
Yea All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant o f- .building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
It havardous air contaminants as defined by the Bay Ama Air Quality Management all new materials for inspection.
ISlrlel7
GYe.
I have mad Mcluvard ,materiels reyuiremens under Chepecr 6.95ofMeCalif¢-
niaHcalMASafctyCWc,S tiwts25505.25533ud25531.IundcnuM Mulfthe Wilding
data oat currently haw a tinsmt.Mat it is my m,pomibility m notify tie occupant of Ne
myviremen Wmet poor¢is ceofa Cenificacof Occupancy.
Signature of Applicant Date
.uuncrorauthorii,editgeof Date All roof coverings to be Class "B"or better