01030042 CITY OF CUPERTINO
BUILDINC DIVISION PERMIT CONTRACTOR INFORMATION:
BU11,DING ADDRESS: PERMIT N(1.
10665 MARTINWOOD WY HOT WATER INC 01030042
JOINER NINE APPI.ICA'1'ION SEE DATI:
JOAN ANDERS 2531 GRACELAND AVE 03/09/22001
PHONE: SANITARY NO. CONTROL NO.
(650) 298-8494
crz ARCHITEC*I'/ENGINEER: BUILDING PERMIT INFO
OOa BLW ELECT PLUMB MECH
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Y.1N LICIaNSISDC hoarsen!
DECLARAOON Job Description
1 herr'hy atlr1111 that I an,ofhe ands,provi.kinn,kl.,CuChapter 9 a,o,been,e
°:Zn 1_-w with Section]O(llgof Ui,i,inn iol the¢usinc.,s and l'ndex,innz Cdde.and my li«nee
�xi- i,in ml toneamdetfcet' INSTALL WATER HEATER.
'M2 i 2 License Clus, 1.ic.W
O w Date Conorc",
uaS a [
1 ARCHITECT"S DIECLARAI'ION
C a.O 1 undersand illy Ohm,shall Iso keen is pante.cont,
rc'da5.,w /n
\•6 0 o Licensed Proresst el
(3WNER-It131l.CEIR DECLARATION
m y 1 henry amen mal 1 1. cBusin Inns the comraetnr's :Anyc Law rot the
F " following raeoa Iknon ,]omou Business and Pml dic o li Code:Any city urrm my
S ek which of,j ce n peal.:.to aonsl tech ober,improve.It"nonh.or repan::sky suumme
a. pool l I. 1 pr rpt' II 'I pc' n1 11 :get.,'. ten
I...n r .sap tare th p knee I to, 1 fchawor9 Sy. FL Floor Area Valuation
Ick g 1hStation k ore a fle H : dV f. Ctdc) $
aSe.io 7exempt.anyan,nend the hasslot lhd. t%doc ..o o.Any,'okttlt - $StDO
of Section om]¢31 s iv any,,retial for a pemki.whRen me upplicam m a civil Penalty
Ont.mare man ace hundred dollars a5IN11. APN Number Occupancy Type
❑I.a,nwhe,ufilm prolleny,orter employee,wilh an','o"heir sale annperomion. :?F,936121`27_
will do the work,and the amenum is not intended or offered for sale(Sec.NHJ.
:no unit Prate. ,Cndc:'Iin,Comnet,,,s l.ieenoe lakw thea mil apply It,roil Required Inspections
.no:,of proltcny W ho lhands or impro,s bemun,and who dno such work himself
or through his own employeesprovided that ouch improvements am not intended or 204 — UNDERFLOOR FRAME
otterdd to,rade.11,hole,le,the building or improocmcnl iv sold within ane year of
anpledkn.me owoenbudner will have the burden in making that head not bald or 301 — ROUGH PLUMBING
imp"m hnparp"se of"ale'` 303 — ROUGH MECHANICAL
O I,a,awns of In.prnpenr.an exdu,iveq eon":"io,wink licensed nn,,.1111 m
construct the project(Sec.]IDy Business and Professions Cdde:)erne Contract,,,', 304 — ROUGH ELECTRICAL
Lice o Lnw disk, an::pply rot n sun of property who build,o,hoprn e,mercor' SOS — FINAL ELECTRICAL
and who mnaa, for web pn,fees with a rontrroemr(al liren,ed pro una, ,,the
CoMpololr.Licen.kcuw. S07 — FINAL PLUMBING
01 am exempt kinder See. .li&P C for this reason
Owner Dale 508 — FINAL MECHANICAL
WORKER'S COMPENSATION DECLARATION 514 — FINAL PUBLIC WORKS
1 hereby a.rrtn under penally of perjury one ol'me Ildlowing deciaralion,
❑ 1 have rood will Innnmin a Ccniacvm of Consent rot self insure,for Worker's
Com,mottion- a, pnwidnl for by Station 37011 of IN hulatr Code for the
perfumunm of the work for which.hi,permit is issued.
01 have and will inai lion Worker's Connlwm,'eion Inxurmne.as mored by Section
3700 of.he Latin Code,far the peformanm of the work for wtheh this permit i,
.wed My Wmo,e,Cn niNnsa.ion Imunnce eerier and Policy number are:
Cartier. Policy No.:
CCR I'IFICSOON OF EXEMPT[ON FROM WORKERS'
CGMPENSADDN INSURANCE
Orin section need not be,completed it the permit i1 for one hundred dollars
do11N11 kr los.l
I ccoify that in the performance of the work for which this permit is:sued,1
,fill bol uanploy ,it,per .my nontnn r es m beconm srhjum m the Workers .
Comisen.,mion Irwn al ci llfomis.Dam
Applicant
NOTICE'1 f t APPLIC\NT'.If,after making this Cemfickte of E,enptik,o you should
become subject to the Wicker s Conkpensutlan pmeision,of the Lmor Code,you maw.
Q O forthwith comply with such provision,or This permn shall be deemed revaAcd.
f y
CONS'FRUC'I'ION LENDING AGENCY
1 herby arms that there is a combustion lending agency for the performance
R7 of do,work for which this pendl in issued ser.3197.Ci,C.)
0. ❑ Lander',Name
7 z Under',Add.,,
U O 1 eerily blot 1 hrce mud 11111 npplieinil oma Stam Ana meaMwe at....„tisk i,
(s F. cornet.I ugro m comply with all city and county ordinances and.state laws wiring /
Q U m building emmution.akin hereby authorize representative,nfthis city u,cmerupon
G3] mw
e uhnvcmmuinncd norel y at ir.vpektinn p.gmsa.
E' G (We)agnrmsascholomnily and keep hunnlesskhc Cityol Cupcnino again.,,
CA liabilities,judgments,costs and expenws which may in any way uccme against said
U yinAPPLICANH UNDERSTANDS AND WILL CO
„. cyacmcogo it
A MI'hYWITH ALL NON1'OINT Issued by: Date
SOURCE REGULATIONS.
Signamn:ornpNicand'onmch,r D.lfk Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or mare building occupant store or handle h afros,material Type of Roof
as defined by the Cnpe.inn M oolfIpa1 Cade,Chapter 9.12,and Om Ilcnhh and Sutmy
Code.Section 255321.1!
O Ye, ❑Nn All roofs shall be inspected prior to any rooting material being installed.
Will meappr.nlhrfuture l;wldin,oc p:mink,00,
took, omdc,ice,wmieh If a roofis installed without first obtaining an inspection, I agree to remove
emit haeallous air contaminants w donned by the Bay Area Air Quality Management
is" ”! all new materials for inspection. Applicant understands and will comply with
O Yas ON. all non-point source regulations.
1 have read the h o,mous mamrinls rcyulrenterts rarer Chaiae,6.95 of the
Cal bornia Henan&Safety Code.Section,25505,25533 and 25531.1 understand mut
if the building dons not currently have a tenant,that it is my m,nisihility to notify the
cupam of the m9uirnnents which must be mil prior to issuance of a Cenircam of
(kcupaney.
Signature of Applicant Date
ow.ma,romhodredagent Dole All roof coverings to be Class "B"or better
_� OFFICE /.