04060004CITY OF CUPERTINO
'
BUILDING DIVISION PERMIT
G"O.NTI2A.CTOR MO MATION
BUILDING ADDRESS:
74n NRWRnM AV
ALL/VALLEY PLUMBING
1EI41ITN0..4. 060004
OWNER'S NAME:
PERMITLSSUUEDATE
MILE LE CLAIR
E;
SANITARY NO. CONTROL NO.
(510)376-4816
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
St. as
(�
LICENSED CONTRACTOR'S DECLARATION
Job D 1
1 emb affirm that 1 am licensed a rovisloes of Chapmr 9 (commencing
wills eth ] )of Division3of the Bu 'rte dlhofcuiom Cade, and my license is
in fat lforce ear t. 7gK00
(J'
CHANGE OUT WATER HEATER
Lim . Lk, M
am Cant°"°' -
ARC TPECIS DEC ION
NOV -f5 2004
1 unch rasend my plans shall be used as Public awards
Licensed Professional
OWNER-BUILDER DECLARATION
BUILDING
flarn(See that 1 exempt from the CrdwinC s
1 hana,moo Anyca. Law far the
n
. 1. Business and Prafdemoli Code: Any city or county
following moon. (Section ] :
which requires a In cost alma Impress:, ore pair awcmm
e,Permit o
acquires h permit t ed
that h)its issuance,rsu re qui res Neapplicant for suchpermittofIe5signedstatement
he
Sq. Ft. Floor Area
Valuation
(commas ingwitpursuantcodecofDiviovoftheComsiness nd:ProeLeonsCodtcrY
of Division Business and Professions Code) or
pttSection]anti)
thammes exempt th slagad
deet he u eaemps deemfram and Ne bssk for the alleged exemption. Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
e10 0
Occupancy Type
not mom Nan fin hundred dollars ($500).
❑ I, asownerofthe property, army employees wide wages ere,heirsolecompemmion,
will do the Work, and she mrsum a is notlmanded araffered formic (Sec. 7044, Business
and Professions Code: The Contracem's License Law ems not apply to an owner of
Required Inspections
property who builds or Improves thereon, and who does such work himseIf or through his
awn employers, provided than, such improvements are notimended cropland formic. If,
however, the building or improvement is mid within one year of completion, the owner
builder will have Ne burden of proving deet M did that build or improve for purpose of
sok.).
❑ 1, as owner of the property, am exclusively consmming wide licensed contractors to
construct ,he pmjecs (Sec. 7044. Business and Professions Cade:) The Commod's Li.
come law does not apply to an owner of property who Wilds or improves thereon, and
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who concocts for such projects with a eon ractor(s) licensed purauanuo the Conuactues
License Law.
❑ lam consist under Sec. ,B&PCforthismunn
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby ". under penally of perjury am of she following declmatiam:
have and will maintain aCW tiirnm of Camara m self-insure for Worker'sComper-
noon, ss provided for by Section 3700 of the labor Cade, for the performance of the
work far which this permit is issued.
0' 1 have and will maintain Workers Compensation Insurance, as required by Section
3]00 of the labor Code, for Ne perfatmsnceofthe for which this Permit is issued.
-
My Worker Cn came a olicy number are:
�ngg�ion ,InvB'''ace
C'� �('P /�LI✓� icy
JP CERTIFlCATE OF E% ON FROM WORKERS'
COMPENSATION INSURANCE
(Thk section need not W completed ifthe permit is portion hundred dallare (SIM)
or less)
I certify Nm in the performance of the work for which this permit is iss am. I shalfnot
employ anyperson in any manner so as in become subject to lW Workers' Compensman
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Cer iBcate of Exemption, you should
become subject in the Worker's Compensation previsions of the labor Cade, you must
fanhwith comply with such provisions or this permit shall be deemed revnked.
CONSTRUCTION LENDING AGENCY
1 hereby dorm Nat Nero is a construction lending agency for the perfumm see or
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name,
Lenders Address
I certify that I have reed this application end state that the abeve informadun is
correct, 1 agree to comply with all city and county ordinances and sum laws relating in
Wilding vemconaaumion, and heresy a ctIm P representatives of this city a Cara' upon to
abeve-mentioned palmy for inspection purposes
(We,)agree save, indemnify and Mich harmless the Cityof against
gmeto
liabilities, judgmcnu.cosssand expcnaca which may in any way eccmc ageimt Said City
me against
p
/
in consequence of the granting of this permit
APPLICANT UNDERSTANDSp*No WILL COMPLY WITH ALLLLyNON-P INT
SOUS.
RCE RE �TIONi%/:.
Issued by: D
Re-roofs
h.N N/��
Signa of Appliwan�n,+aw,o Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding meupentstom or handle haYMkYs matedal
as defsncd by Ne Calandra Municipal Code. Chapter 9.12. and ek Health and Safety
Code. Section7yo 25532(e)7
Seem.
All roofs shall be inspected to any roofing being installed.
prior material
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
.I hazardous air contaminants as defined by to Bay Area Air Quality Management
all new materials for inspection. -
airin7
C] Yes u
1 have mad the hrnrtiousmaterialsaqulmencnu under Chapkr6.95 orthe Califon
nia Health &9afesyCade,Samom 255]5.25533aad 25534.1 undenundthmif,W Wilding
dos not currency hast a tenant, that it is my responsibility to notify the accts t a the
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rcyuiremcnts which mus, be mel ria naw tin rdrea�gfpwa
-o
Signature of Applicant Date
owner ar aa, ed agwm o
All roof coverings to be Class "B" or better