03010169 CITY OF CUPERTINO -'
BUILDING DIVISION PERMIT ked RAOTORANF,ORMATION
BUILDING ADDRESS: HOT WATER INC PER MI'r NO.
19801 LA MAR DR 03010169
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DArE
ORTIZ GUILLERMO A AND MARTHA D 01/28/2003
IONH (650) 298-8494 SANITARY NO. CONTROL NO.
ARCIIGIiC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
00 Lm that I.DCONTRd under provisions
Thereby affirm rhatlam licensed def prowi,ion&orChapter v(commencing Job Description
with it n 7000)'If Dov at,, 3 of she i7ditsvand PmAessj .Cod,,and my license is
infalll candefr '/b (/ /Y) REPLACE WATER HEATER
ZOYjZ Dale Clas.
Da C tae
ARC(II"1' ,pa ATIOIN �®
� a� l undmsmnd my pl..as M1ell he u�d us public rccmtls
FLL�„le,
Licensed Professional
APR 0 8 2003
atIamemropiOWNER-BUILDER DECLARATION
K e E I hereby affirm that 1 1. exempl from the Cunvacmrs License Law for the 1 1 1
which re reason.Permit
703 ommetusiness and vs,.de in ih.or Any city morchure BUI�DI
whim requires a permit hs uires the
aafter,pplicant
improve.dcermit t or repair any vrucmm
prior e,its issuance p also rcyu ma pro applicant fnr won permit m Glc s signed statement
ma�yx=x thmheisling With
pursuant to provisions of theeBusiness License Law(ChapterCode)
Sy. Ft. Floor Area $V(iQQ1100
aF$ (commencing with Secfivan and of basis
mfthcelled essand
on.Any vi Coion of
that Section
is exempl ffirreany applicant
li and the basis for dtc alleged excerption.Any l Penalty of
no,none than five
hundred
iwns rot a permit subjects the applicant to a civil penally of
no,more then live hundmd dollars(5508. 0 Occupancy Type
❑I.asowner of the pmpony,or my employees with wages as their sole compenaadnn,
will do the work.and the 9"Chi d is not intended of offered for sale(Sec.7W,Business
and Profusions Code:The Commetofs License law doe¬ apply toan owner of 506 - GAS TE �gmred nspeeuons
pope"who builds or improve themon,and who dues such work himmlf or through his
own empmyecs,prodded that such improvements an,not intended proffered for sales if, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion,the owner
builder will have the huNen of proving that he did not build or improve far purpose of
sale.).
❑ I,as owner of the properly,am exclusively contracting with licensed convectors m
construct the project(Sec.71194,Business and Professions Code:)The Cnmracmr's Li.
cense paw does not apply to an owner of property who builds or improves themnn,and
who contracts,for such projects with a conlracter(s)licensed pursuant to the Contractors
License Law.
❑ I oro cacmpt under Sec. ,B&P C for this reason
Owner Data
WORKER'S COMPHNSATION DECLARATION
1 bercby aR,m under penally of perjury one of IM following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compce.
esti..,as provided for by Section 371X1 of she labor Code,for the performance of rhe
wn k fit,which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as tequircd by Section
-71X1 til the labor Code,fnr the performance of the work fm which this permit i,issued.
My5W,ukc%giicr and Policy num�cr/A�¢/Ca Policy I—.- -/ o ;�ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is formic hundred dollars(S 11X))
less.)
I certify that in the performance of the work for which this permit is issued.I shall or
employ any person in any manner ar as m become subject to the Workers'Compens uinn
laws of Califumia.Date
Applicant
NOTICE TO APPLICANT:11,offer making this Certificate of Exemption,yon should
become subject In the Worker's Compensation provisions of the Labor Code,you must
OO forthwith comply with such provisions or this permit shall he deemed revoked.
z N CONSTRUCTION LENDING AGENCY
PIhemhyo irm that there isaconswnion lending agency forte pufurrommoof
the work fnr which this permit is issued(See.30TI.Civ.C.)
Wti Q [.title,',Name
z Lcndcr's Address
U 0 1 comfy that 1 have mad this application and&talc that the above inf areminn is
Ia. F correct,l agree to comply with all city and county ordinances and state law&minting to
0 U building construction,and hereby arhorim representatives of this city to enter upon the
uJ above-mentioned property for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against 7
y Iialuditics,judgments.costs and expenses which may in any way same against mid City
V 7 in comcyuencc of the gmming of this perm it.
r^• APPI. ANT UNDERSTANDS AND WILL COMPLY WITII ALL N N-I' INT Issued by: Date
SO :GULATIONS.
D Re-roofs
gnaw.of Applic HAZARDOUS MATERIALS DISCLOSURE >ae Type of Roof
Will the applicant or future building occupant stare or handle hamrdous material
as defirmd by the Cupertino Municipal Gale,Chapter 9.12,and the health and Safety
our.Section 25532(e)7
r:1 Yea l6No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fulum building occupant use equipment n,devices which If a roof is installed without first obtaining an inspection, I agree to remove
mil husurdous air contaminants as delined by the Bay Area Air Quality Management all new materials for inspection.
Dishict? ff����
0y. NasNo
1 have mad Ne bru mous materials myuimmenss under Chopm,695 of the C lifor-
nia11ca1N&Salety Cale,Smthmv25505,25533and255W.lundervand thv'rtM Ildmg
does not curremly have a¢nam,that it is my responsibility to notify dotcupa.� nr the
req m envwhich must he mel prof in issuance ofa Cemlicato of Occ b Signature of Applicant Dale
Owner or anthuriscd agent All roof coverings to be Class "B"or better