01040057 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRHSS: - PERMIT NO,
1603 LA PLAYA CT HOT WATER ING 01040097
OWNER'S NAM1:1 API'LICA'IION SUB DATE;.
V
KEITH RIEKFN Pf�l GRACE] AND
04112/2001
PHONE: SAN[LARY'NO, CON'I'k0l.NO,
a c 2 ARCHITEC'PIENGINEER: BUILDING PHRMI'IINFO
O
BLDG ELECT PLUMB MECH
V�E 1=1 CI I-1 I=1
m hICCNSED CON'1'RACI'OR'S DECLARATION
z G 1 hereby alrnm mal am ucemea aemr provi.lnm est cnapler 9(emmmenail,g Job Description
with Section 70001 of Division 3 of the Bmines—rd Profession,Cde.ond an,liana
is in full coneand effect.
I."crw Cl,r" Lic.x REPLACE WATER HEATER.
x
0,6 Date Commova r
Wj'+In - ARCHITECT'S DECLARATION
C�;ON.Q4 I uat...omd my ilan,shall be used as public rccnnl, -
�4 6 p C Licensed Note..ionzl
ofOWNIiR-HI111.Dr:R DECLARATION
to m w 1 heRnY uIRrm that I am exempt from the C.muacnn's Iinm,c Law for,he
F following reason.(Section 7131.5.Business and Pmfeslom Code:Any city or county
�5yj F I] which ngnire.s a permit to cunnmet,alter,infinite.demolish,or repair any urunure _
ce prior tolbixsuance,ahnrcyulresiheappli,t stir.uenper...ttnfileasignedo,am rel
mal he isgcenvalpimmantmda,pnvmi cam.tit inecenlcwmra Liver,I-no.(C[ctual9 Sq..Ft. Floor Area Valuation
Icunanencing with Section mXXh of Division 3 of the business and Profexiens Code)
or that he is exempt Ihemliont and the basi,tar the alleged exemptionAny violation
of Section 7031.5 by any applicant Join permit subjens the applicant m a civil penalty
of not mom than five hmnand dollar,(5500). APN Number Occupancy TSITOU
❑1,as owner of the propny,or my employee,with wages u%their vote cmnpnsainn,will do the work,tied the someone is oil intended ter offend for.ale(Sec.7014.
push....and Prom�io,Come:'we no
n, U....I Law does 1for apply to Int equtred Inspections
r of propny Who builds or improves tbceom,and xho does such work hinv elf
or through his own employees.provided that such improvements am not intended or 502 — FINAL PLUMBING ENERGY
offered for sale.If,however,the building oro immoven em is sold within one year of
innvcpletiun,the mmhuildcr will have the burden ofpmving that he did not mild or r r
mprove lest pagxneofsale.). .-106 — GAS TEST
❑I.:u owner anhc peprty,.,if exem,kcil contracting wilt heemed aontraator,m 507 — FINAL PLUMBING
consumer the pmject(Sec.7044.Ilminen and Prufessons code the Contractor's
Liceme Law des not apply to an otre I propny who build,or inmroves theme,
and who comma, Ibr xuch pn.jccl,will,a centemosin,)licensed pur.mvu m the F�
mtmctLicenseLaw.
Nq
Cp am I exeme mpt under Site .B&PC fou mih revs, LEp
Owner Dam
WORKER'S COMPENSATION DECLARATION 1
I therebyalrinn underpevlty olperietyon,of the tollow'ingdeclarution.. �� O 001
O I have and will nnsin tela a CenlEcate of Convent u,self-insure 1nr'Wnrkais ®�'�D1
Compmprovi
adon, a, ded lit by Sit a 3901 ,1 the Labor Cedc. I'orthc NC
perhsmmnce of the work for which this petit is isms. 'Y
❑I have and will maintain winker'.Contpawmion Inwmnce,a,required by Section
390 of the IZM,r Cade,ror the performance of the work for which this permit is
issued My Worker's Compenufion Insurance carrier and Policy number are:
Camc,: Policy Net o
CERTI EICADDN Or EXIiM IMON FROM WOR KERS
CONIPFNSATION INSURANCE
(This.anion need not W completed if the permit is for one hundred dollars
IE 110)or less.)
I certify that in the performance of the work for which this Permit i.issued.I
modl nm employ any person in any Trainer so its at become subject to the Workersi
Con.se—fon Law,of Cullfmnia.Duro
Applicant
NOTICE.10 APPLICANT:If.atter snaking this Cerificae of Exemption.you should
Q O Monroe subject to Iha Worker's Co wo,alon powimon,ol thhnr e LnCode,you elm
forthwith comply wiles such pmrimim,of thi,Permit shall be themed revoked.
z
CONSanUs. oN LENDING lending
aNCY
a ! Thereby ultimo That merei,s conal Nee. Iendingagency for the performance
of the work for whlcM1 his permit u issued(Sec.31)9).Ci,C.1
0. A Lender's Nome
5 J LenJcG Address
U Q 1 eenlfy Iha I base real this appliea l mal sows Iha,the above whomm nn is
h E~' cured.1 agree to comply with all city and county ordinances and,state laws relating
Q U u,building construction.and hereby authorize representatives of this city it)enter upon.
>, W Ne nbovc.nlcmin led pnpeny lin'imPectinn Puqurscs.
F L (We)agree n,more, ndenaily and keep Knorr...the Cnyof lbperioo againrl -
rn liabilities,judgments.Cents and expose,which may in any way accme aga'mn said
U % City in croseya...c of the yma in,of this Permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGO LATIONS, y'
&igtamreuf Applfca,WC'unnaclor Dec Re-roots
IIA7ARDOUS MATRRIAM DISCLOSURE
Will the applicant or future building occupant mom or handle Weardous material Type of Roof
,s defined by the Cupninu Mm,iclpul Cele,Chapter 9.12,and the Ilcahh:md S:dety
Code.Section 25532(a):'
O Ye. ClNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicants future building occupant use equipmenl or devise.ouch If a root is installed without first obtaining an inspection, I agree to remove
emit hvardou,air commninants as defined by the Bay Area Air Quality Management
. District all new materials for inspection. Applicant understands and will comply with
ave, TD No all non-point source regulations.
1 have read the Iamnlnlas materials requirements under Chaper 6.95 of the
California acallh k Safety Code,Sections 25505,25533 mad 25534.1 undersand Inns -
if the building doss not currently have a mount,that it is my esporrodahly to notify da
a,.,a.,of the requirement which nm.st be if...prior it,issuance of a Cenificom of
Occupancy.
Signature o1'Applicant Date
Dwain or mmoll,el""a Dan All roof coverings to be Class"13" or better
OFFICE