00060161 (2) 05 MEDINA CT" WHICH HEHIEHS UNLY utuauioi
Cli OF CUPERTINO
BIUI'1t1c990'9)AVID A WONLI&LIE CONTR �OI I S��It���N: 06/23/2000
BUILDING ADDRESS PERMIT NO.
(415) 349-3747
OWNER'S NAME AI'PLICA'1'ION SUIT DA'Z'E
ONE: SANITARY NO. CONTROL NO.
M as o ARCIETEC IENGIWaiR REPLACE 50 GALLO WRTF_HR +IEATENf(INFO
ppp BLDG HLRCI' PLUMB MECH
I_1 1;=1
j LICHNSED CONfRACfOR'S DECLARATION Job Description
1 hereby ofiinn that 1 am othlicensed under provismns of..Code. (commencing
�Ntw wish Sectian]IXp)ofDivislon3 ofne Businea onJ Pmfessiens C,de.amlmylicense
zm :J is in full hone and effect.
s ex a License Class Lin,M
O n O Dwe SDECLer
'al iiaO t;; ARCHO'Ee'r'S DECLARATION (/ I
1 undetxinnd my pion,.hall bellied rex pnhl'm recvrdf,
x < Licensed Professional �!
c OWNER-BUILDER DECLARATIONa.
/
6-, 1 hereby affirm that 1 a exempt from the Contractor's License Law for the
I-z i lidlowing realm.(Seaton]fIJLS Business anJ I'mkssiens Codc:Any city m county
f s o which requires a permit to construct,alter,improve,demoinh,or repair sena sthicmat 34215058. 00
W
jt, m0elo itsissuance.nBu requires the applicant lan
I'll such pvarin lileanibn<d m
Xlmenl
that he i, actocalp ,tI he p f[lie c I ter's License Laok(Chapter 9 Sq. Ft. Floor Area Valuation
(can b ',hs' 'i 7000)",lD,i,laa i atII B II I Code)
arlhnl he is exenpli ,rat..o.seine nasi,la the.d1c,ed ex,mptn Any tiolal it FINAL :PLLMBING ENERGY
of Section 7031.5 by any applicant for a peri it vuh,iecn.the applicant m a civil penally
(it not more than five hundred dauar, S5(w,. APR3&mberGAS TEST Occupancy Type
01,as owneraf the progeny,army employees wfill wages w mcir sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.]IWJ.
❑usiness and Profession.Cade:The canlracmr.License Law does nal apply to ai _ Required Inspections
,woe
r nr p v,kny Win milds a improv,thenan,and who dues such wank himself
or sled ah hi,,,.,,empWyccs,provided that such inrymveis III
Invi nut....ended ser
,onnor for vdc.IL ba re the:militia n :ogre cit in rdul he did o t hold
of
t„m,...c far theaw,of sc.) will hove the burden of proving Ilia,he did not buil)m'
nmve ran patpuxn ser xale.y
01,as owner of The pmpcnv.am esclusively contracting with licensed conlonchi s to
tonsimet the project(See.iMs,Rosiness and Professions Cede:)The Contractor's
License Law does not apply to an owner or property who builds or improves theater.
and Lino contract, far such projects with a eommI licensed pursuant m the
Cm ,Lebas Lieenm Law.
0 I an,exnopt under Sc,. .B k P C tar Ihis mown '
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby if res under Penalty of perjury one of the fallowing declarmisav
0 1 have and will maintain o Cafficum of Consent to sei-inwre for Worker's
Gmi,maion, us provided for by Sarin 1]W of the Lubar Code. for The
perfnemeace of the work ha which this pcnnh is issued.
❑1 have and will h niowin Worker's Cnu,pcnwlion Imomice,as requimd by Salon
1
]0(1 of The Lima,Gide,for The Nrfnnn:mce of'be work for which his Permit is
issued.My Worker's Compensation Inmr:mce carrier and Policy number are:
Canter: Policy No:
CERTIFICATION OF ITXEM19[ON FROM WORKERS'
COMPENSAI]ON INSURANCE
(Thin snmian aevil.,at he annplctul II'the ncnnif is Iles ane hundmd dollars
S 10(11 or less.)
1 charily that in the Iwrfnrillanec til the work far which this permit Is issued.I
.hull not employ any person in any manner wt as in become subject to The Workers'
Clian't cation Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,milennaking avis CeniGc n,of Exemption.you should
become subject the Wa .elon
s Compensation Frovi: s or the LaMyou mus
,r Code, t
Q Q ttd
t'onhwilh camply with inch prnvisiune or this peonft shall be deemed rovokcd.
Ft� CONST RUCI'I ON LEN U I NO AGENCY '
C 7Ihenhy uhinm that them is u eonxlmnim lending agnmy for the perliamrnce
of the work for which this permit is issued(Sec.309].Civ.CJ
y Q Lender's Name
.T 1<ndcr':Addren,
V C 1 certify that I have mad this application and state that the above information in
❑+ p v,ma,,1 naive m conTply wins all city and oomny Mire nces and late law.refiling
Q V Its huiaing animnmdon,Land hereby um]mnim rupmwnoniviceat this chy a,eater a's,
W the ub,,vo-m<minunt Properly for inspcetion puipaml.
y (We)ugtt,tri all,Indemnify and kap hmmless the City nr Ceara o again.,
V) liobilibe,.judgments,ensu and exl'<nwn which moy in any Limy raceme against said
U 7
City inconsequence DofiM graining of WILL
peon::.
SOURCE REGULATIONS.DSAND WILL COMPLY WRHALL NON-POINT Issued by: P Date
SOURCE REGULATIONS.
Sigwmre of npplicnnUCommcan Date Re-roofs
I IAZARDOUS MX1 TRIALS DISCLOSURE
wits dTn apnlinam ni mwm adlnliTg«nnnam nom ser IL:indw lianllnax mntcdal 'Type of Roof
as dotincd by the Cupertino Municipal Cole.Charter 9.12,and[lie Hcuhh aid S.e.,
Coca.pYcsSection 2553200! 0N
All roofs shall be inspected prior to any roofing material being installed.
Will the upplican or future buildingsecapant use egnipmenl or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
mit hsmNnus air aonmmitmni,as defined by the Bay Area Air Quality Management
)iarlen , all new materials for inspection. Applicant understands and will comply with
Cl Y., IDNo all non-point source regulations.
6#1 I have read the harmrloux mumriids«'mbar.ns under Chnpmr 6.95 of da
Culirnmia Hadfil N Safety Ctdo.Sections 25505,25533 and 25534.1 undersand that.
it the building dome cul currently have a mount,that it i,all respnnsi olity Io notify the
ecupaw of the"When nits which niust be met prior to issuance of.a Certificate of
ofemal Signature of Applicant Date
Owner or nathoriea agent Dan All roof coverings to be Class •B•'or better
OFFICE