00100229CITY OF CUPERTINO
HUt.DING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRIISS,
,
PeRMrr NO21395
MONROVIA ST
T1 IRT 1.10TER HEQTFRR
I -'
OW NF,R'S NAME:
APPLICATION SUB DA] E
iONE:
—
L-
SANITARY NO. CON'TRO1. NO.
ARCHITECDENGINEER:
BUILDING PBRMtr iwo
BLDG HLECIPLUMB MUCH
C7 IJ IJ 1=1
LICENSEII CONI RAC'[OR'S DECLARATION
r Job Description '
I hereby alfino (hat I tun licensed under pro,mons of Chapter 9 moundetwing
with Stadion 7001Division l of the Businesx and Pmfen,ions CWe, andmy license
in ['.If m
If a atenol.
LiCCmCClax 1'it.# -
REPLACE 40 GALLON GAS WATER HEATER
Dare Common,
A RCH I I. T'S DI.CLARATION
1 understand my plan shall be used us public rcead,
Licensed Prnfessinnal
OWNER-BUILD(?R DECLARA'T'ION
I hereby affirm that 1 am exempt from the Contractor's License law for the
follnwing mason. (Section 7031.5, Basins., and Prof ,inns Cale: Any city or eoumy
which mi,dim, a wroul m cans......, alar', improve, dcinnI nh, fir repair.... structure
'
prier m its issuance. also requires the applicant for such Noun to ale a signed statement
Sq. Ft. Floor Area
Valuation
mat he inreemeepurominth, the provision,ofthe CierworsLicense Law (Chapter 9
(commencing,dh Smtim, 7100) e1' Of....nn 3 of the Baine, m d Profusions' Cu I,)
or that he is exempt theefmm and the basis for the alleged exemption. Any violation
},>
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
APN Number
Occupancy ype
or not prom than rv, hundred dollars ($500).
C h as owner of the progny, or my employees wish Inge, as their pole compensation.
rt_. •J v .r •
will do the work. and the wo,li a i, no, intended or obered for solo (Sec. 70.14.�r.
Business and Pon e,,,ons Cde: The Contractor's Lieenne Law does not apply to an
egUlred Inspections
r of property Who Milds or hopmven thereon, are who does such work himself
;set
r tIt his own eo,plt,yena. provded'j,i, h hnpmvem&" are a„ ;metaled to
502 — FINAL PLUMBING ENERGY '
ofreread lin sola If, however, the huilding or improvement is mid within one year of
caplet ,thee er-builderwillhavetheburdenofpnningthathedidnothuildin
506 — GAS TEST
Icompletion,
"1wka pamow 'If ole.).
507 — FINAL PLUMB N
C 1, as owner of the property.a exclusively contracting w ith licensed contmcmnto
fit, (Sm. (See. 70.14. pot and I`ndes , Cod,:) Tim Conmacmr's
Lmmad
ica,, Low dee, nm apply in an owner of progeny who Wilds or improve, thereon.
and who comness for .ouch pmjexis with a commends) licensed pursuant to the
'
Cunion ext, Liaanc Law.
C l am a", Luecr,er Sec. . ❑ .q I' C for this rcisn
/
Owner Date
WRKiiR'S CUS1I`Date ION U13ChARAT1(lN
I1
I hereby affirm under M1nally of perjury one of the follnwing dedurmina,:
O
J 1 have and will maintain a Certificate of Consent fa .elf -inure for Workers
,
Cmnpemmion, as provided or by Section 3710 of the Lahr Code, for the
pednrmam. of fhe work for which mix permit is issued.
❑ 1 hove and will maintain Worker's Compensation Inxurance, as returned by Section'
3700 01' Iho Labor Cada I Ila, wd.n is am of the work for which this permit is
sued. My Workers Connpe sanum Insmnee carrier and Policy number am:
Carmen. Policy Na:
CERTIYICAIION 01; EXTMP ION FROM WORKURS'
C0MPpNSAl'ION INSURANCE;
This mount need not he completed it the permit is for one hundred dollar
`
(5100) or lease.)
I cenify that in the pfrloon duce of the work for which this permit is road. 1
,hall wt employ any person in any manner m as to become subject to the W'orkeK
Cmn.cosaio I Laws of California. Data
Applicant
NOrICE'10 APPLICANT. If. after making this Certificate of Exemption. you should
hxmnc xabjeer,o the Workers C nipcnxat inn provision, of the Labor Code. yon must
forthwith Comply with non, provisions omnis permit shall he dermal revoked.
CONSTRGCIION L[.NDING AGUNCY
I hereby al'ibm (hut there is a cmwnunion lending open, for the for Ce
of the work for ishich this permit is issued (Sm. 3197. Civ. C.)
Lcndus Name
,
I.cndef, AMC,,
I certify that 1 have read this application and state thin the above information is
ly with all it, and Is 1y ordmand onlaws relating
rim. I agmc to comp;,am, ce
i
tobuilding conswmion. find hereby authorize reprmairmiec% of this dry to enter upon
'
the above nominated property for inspection purpose,.
(We) agree as carve, indemni I aM keep barn less the Cay of Cuiertim, against
liabilities, judgmcm%. Coq%and ,,,,cues which may in any way aceme against said
City in norwa, enm of rhe granting of this pennil.
UN URSIANDS AND WILL COMPLY WITH ALL NON -POINT'
Issued bTIONS.y: Date
AOUBCANT
Signature of Applicant,Conwmtor Date
Re -roofs
HA ,%RDOUS MAT ERIALS DISCLOSURE
Will the applicant on future building ocsmp:mnmm or handle hezmlons material
Type of Roof
as defined by the Capetian, Mwticipal Code. Chapter 0.12, and the Health and Safety
Cede, section 2553200'!
C Yes 0 N
All roofs shall be inspected prior to any rooting material being installed.
Will ase a,flicant or butfire huilding meapant ase egnipme,lm dmlm+which
If a roof is installed without first obtaining an inspection, I agree to remove
:it harardous air contaminants as defined by the Bay Area Air Quality Momparst
men
all new materials for inspection. Applicant understands and will comply with
13Ye, °Nn
all non -point source regulations.
I have rend the hvanlous materials reryimmens under Chapter 6,95 of the
California 11.111, de Safety Cale, Sol x,25505,25533 and25534. 1 undemmnd t hat
,
if the building does Dar curendy have am ..... that it is my rcspemsiM1iliry to nmiiy the
pam of the retimmmentc which must to mel prior to issuance of x Certificate of
0.cu..pane,
Signature of Applicant Date
All roof coverings to be Class "B" or better
own,, or author aed agent - Date
OFFICE