00060161 CITY OF CUPERTINO lax-kBymW
BUILDING DIVISION PERMIT CONTRACTORINk'ORM ATIO ; urLWATIE
BUILDINGADDRESS: WATER HEATERS ONLY FMNIIINO00060161
OWNER'S NAME: PERMIT IEBUE DATE
NE: SANITARY O. C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONRIACfOR'S DECLARATION IOb Description
x 1 hereby affirm Net 1 am IuomeO under pmvivumof Chapter 9(commencing
with Section tion,Division J of Ou Buaixuand Profesdnm Code.+nd my Licata¢u
d � infullfx.eandeffec. REPLACE 50 GALLON WATER HEATER
j License Class Lic,If
np Dam Commell r D
r ARCHITECTS DECLARATION
Sy�< 1 notionalmy Plans dull my used as public rtcnrOs
7 U
G Licensed professional
OWNER-BUILDER DECLARATION
rayq9 1 Mason.
affirm Nes I t. exempt from the CnmnnC's e:Any c Low for the / t/
ip0 whichrquors a.(Sccuut T(DLS.Business and w.cerium Code:Any city or county
U —t
whicM1 rtyuirts a pewit m cnnswc,,elm,,imprnw.JcmOlish,or repair any swcsure
Fiy
print mits boo,occ.also ex,iresthe applicant for such permit toriiluSigned Statement Valuation
that< heislicensodPuswan I.NC Provisions of the Conuacsur'sliec.Law(Chapter 9 Sq. Ft.Floor Area
¢�$ (commencing with Seetion7")of Division J of tW Boutessand Profeasiom Code)or
— that be u exempt snertfrom andftbmu for the alleged exemption.Any violation of
S«adn 7031.3 by any,.PPIi.'rm.+Pewit Subjects de.,]it.,tu+ebil penit,of 34' $Cro0 Occupancy Type
SEE mart,nen Rw hundred dollars(x500.
1.SEE Owner ofshe property,m my employees with wages m their sole compensation,
willdo thework and the structure is mumunded or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License law does not apply w an owner of 9 P
property who builds or improves thereon,endwhodocssuch work himselfor through his
own emplo,res,provided that Such improwments tie not imenisd indicted for C.k.IL
lure,..Ne building or improwmant is Sold within one)ear of comPlcuon,Ne Owmcr-
builder will have she burden of proving Nu he did not build or improve for purpose of
Sale.).
I,as MOST of Be propcny,am UClusively contracting with licensed contractors to
construct the project(Sec.0064,Business and Profasidm Code:)The Comncsor's Li-
me law docs not apply in on owner of p mpenY who Wild,or ImVrows thereon,and
who contracts for such pmjecu with a eomrector(s)Beamed pursuant to On Contrecmrs
License law.
❑I am comp,under Sa. B g:P C far out reason
Owncr Data
WORKER'S COMPENSATION DECLARATION
1 hereby+Mm under porosity of perjury one of the following declar•sions:
1 haw and will maintain a Ceri fcam of Consent m self-insure for Workers Compere
wins,ss provided for by Secudn 3100 of the Latin,Code,for the perforall.of the
work for which Nis permit is issued.
❑I have and will maintain Worker's Compensation Insurance.ns res ined by Section
37Of the labor Code,for Ne perfowanec of Nor work for which this Pewit is issued.
My Workers Compensation Insurance carrier and Policy number ace:
Cartier. Policy No.:
CERTIFICATE OF E%FMPTION FROM WORKERS'
COMPENSATION INSURANCE t
(This section recd nm W completed irthe)ewit is(men.hunched dollars(Slip)
or loss.)
I cer ify that in the perfnmance of the work for which this permits is issvad,I shun not
employ any person in any manner so m In bocome,subject to the Worke 'Com,cosation
Laws of California.Dec
Applicant
NOTICE TO APPLICANT-if.after making On Cmufau of Demotion".you should
become subject to the worker's Compensation previsions of Ne labor Code.You mon
.Z foMwi,h comply with such provisiom or this permit shall W deemed hewked.
ZO CONSTRUCTION LENDING AGENCY
�.. I hereby affirm on, is a construction lending agency lot the Performance of
y> deo work fur which this ..it is issued(Sec.3097,Civ.C.)
{k1 Q Landers Namc
6. Landers Address
V 0 1 certify deal 1 have head this application and sum Neu den above infmmauun IS
Y.t—' coned 1 agree to comply with all city and county ordinances and sou laws heisting m
O V Wilding
(We)a gree n,and
w.indemnifya d eprcien less of this city socnmrupon the
�LL1 abovcmcnfuned property for inspection PurPosea
(We)agree tu Cove,indemnify end keep harmless the City of Cupcnino against
F"rjj Ilabiliva,judgmenu.ensu andespensa which may in any way acme ageimuud City
V z income,ucnttofthe grantingofthis permit. DEte -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicantAConwcmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building Occupant sort or handle h ctin kno manual
as defined by rise Cupertino Municipal Code.Chapter 9.11,and Ne Health and Safety
Code.section 15571(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya ONO
Will the applicant or future building Occupant by,equipment or dcvias which If a roof is installed without firs[obtaining an inspection,I agree to remove
i,incondous air conummants m defined by Nor Bay Area Air Quality Management all new materials for inspection.
Di
❑Yes ❑No
I havemad thehuuN meerialsmquimc nmunderChapur6.95ofdesGliror.111110E7
Health&SafelyGodc,Secduu13505.255JJ ea1255J4.1 undersuM thatifthe Wilding
rs not cuwntly hoc a tenses,cut i,a my respofuibili,y m notify the occupants of theyuihemats which muss be mm pdnrmissdana rtes anifamOr Occupancy Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or amhoriveJ agent Da,e