021001834
0
CITY OF CUPEKI'INO
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BUILDING DIVISION PERMIT
CONTRACTORINFORMATION•
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FIgD +JAPgI7'MARIA ROSA WY
WATER HEATERS ONLY
PRRMI'FN02100183
9RNYPTA & ROD SINKS
970 E. MAIN ST, SUITE 200
APPLICATPU6}'I°Y8T}`2002
IONF.:
(415)566-2209
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINFFW
BUILDING PERMIT INFO
BLDG ELECT PLUMB MGCII
0 0 0 0
LICENSF.DCON RACfOR'S DECLARATION
1 hereby shim, that sed at 1 am licenunder provisions of Chapter v anmmcocmg
`Qy p
with Semon 7(XX))of Division 3 of dw Business and Profeminna Qule, and my license is
REPLACE WATER ArIsfftion
HE
in part forcerttL (/.[��J.y
in i'trow loo, .
Class Lia i�JFfy—'1GSl...s
Date contt[[a}airz la'1fiTn
ARCHITECTS,f�CLA A N dNL�
1 understand my plans shall be used as public lice Js V
Licemed Proless nall
OWNER -BUILDER DECLARATION
I herchy affirm that 1 am exempt from the Contractor's License Law for the
$769
hollowing reason. (Section 7131.5, Business and Ponessions Cndc: Arty city or county
which requires a Permit in conamcl alter, improve, demolish, or repair any structure
poor to its issuanm, also requires the applicant for such Permit o Glc a signed statement
33g6H19F@&2A&@
Valuation
that he is licensed pursuant to the provisions of the Contractions License law clouir 9
wommcncing with Section 7041p of Division 3ot he Business and Prowtaions Code) or
that he is exempt themfmm and the basks for the alleged exemption. Any violation of
b UAPN NOccupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of
not more than five hundred dollars (S500).
506 — GAS TEST
Q I, m owner of the popcny, or my employees with wags as their side eompersmfion,
567
will do the work. and the slmnum is not intended or offcrtd for sale (Ser. 7044, Rosiness
C n5 ections
and Professions Codc: ow Contractors License Law does not apply to an owner of
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q P
property who builds or impovesth mm, end who does such work himself or though his
nor operated or foelilalr-
own 1.
esuchimprovementsis
the building i pr sold completion
uilderhowever. me building or improvement sold within one year of complction. the rose of
hack.) r will have the burden of proving that he did not build or improve for purpose of
/
sal .).
O/
I, as owner of the property. am cufessions wodl Conmfaor'sS
:) The t.
Business and Professions ati The Corrector's
, Business and
ds rad
c nsc law c tsef not apply m an owner of property who ood p or improves Contractor's and
ecrstocnhe does apply to an
whocontactsLacD for such projects with a contianor(s7licenmJ pursuant m me Contiacloi s
Q
License Law.
❑ lam exempt hone\ Scc. , B A P C for this reason
/ Date
sCI��TTJJ
S :N EC ATION
'hereby affirm under Penalty of Perjury one of me following declarations:
I haw and will maintain a Certificate of Conecnno self insure for Worker's Compen-
sation, as provided for by Section 3701 of the labor Code, for the Performenac of the
walk for which mil permit is issued.
❑ I have and will maintain Walker's Compemalion Insurance, as required by Second
3710 of the Lalcs Cndc, for the performance of the work fire which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number art.
Carrier: Policy Nu.:
CERTIFICATE OF L%EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
mu, section need nal MmmpleteJ if the permit is forone hundred dollars (SK(h
It,,)
1 certify that in the Performance of the work for which this Permit is issued, l mall no,
employ any Person i doer so isl 'smesghjcc he Workers, Com penwlinn
Laws of California. Ual
Applicant
TO APPLICANT: h. a ler mntakCcrThcalof Exemption, you shoo ld
c subject to the Worker's Compensation provisions of the "hot Crate, you must
5G
wilh comply with such provisions or this vera iLshalI be doomed wwlard.
CONSTRUCTION LENDING AGENCY
I he why affirm that mere is a contraction lending agency fur the performance of
the work for which this Form it is ssued (See. 3197. Civ. C.)
Lender's Name
Lender's Address
1 certify that 1 have wad this application and sow that the above information is
correct. 1 agree to comply with all city and county ordinances and stale laws mlating to
building constmclion, and hereby aummire representatives of this city to enter upon the
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above-mentioned property Fir inspection purposes.
Wo) agree qs saw. indemnify and loop harmless the City of Cupertino against
liabiliucs,judgmerm, taxer and expenses which may in any way aceoc against mid City
n cuequence df the gaming of this Permit.
in
UNDERST DS A L COMPLY WITH ALL NON -POINT
Issued by: Date Cw
SOURCE RE .ATION lO /gyp lOs
Y G�
r (
Reto
Type of Roof
arc of Appucanticomm nor me
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant smrc or handle histaminic, mrcrial
as defined by The Cupeninn Municipal Code, Chapter 9. 12. and the Health and Safety
mde.Section 255.32NT?
All roofs shall be inspected prior to any roofing material being installed.
0 Yes JRNu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or mmee building occupant use equipment or devices which
emit haneduus air cnnmminames as defined by the Bay Area Air Quality Management
all new materials for inspection.
Dunn?
s
C] Y's [?JNo
I haw mail me haszrdous materials requirements under Chapter 6.95 of the Calton -
ma Realm 5 Safcty Code, Section 25.15.25533 and 85]4.1 umkrstand that if but holding
does No currently have a tenant. that it,, my res,muhilhy to annoy the occupam of me
wquiomenks which muabe tenor wof a Cc ificale of Occupancy.
Signature of Applicant Date
(�
Z be Class "B" better
All roof coverings to or
Owatonna Igc 1t.