00090091CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMITNO
OWNER'S NAME» —
_HGTWATER 1PI(3
APPLICATION SU13 DATES
�.
AVE-
09
ONE:
— " 1 614AGELAPID
SANITARY NO. CONTROL NO.
1
c ARCHrI EC17ENGINEER;
(650) 298 8494
BUILDING PERMIT INFO
BLUO ELECT PLUMB MITCH
i
IJ f=1 I'-1 LJ
LICENSED CONTRACTOR'S DECLARATION
Description
I hereby affirm thin I am licensed ..tic, pnnh%i)nc of Chapter 9(ft mhmencing
.lob
j wash Section 700)of Ufvi,i 3ofmc lammaievcnnJ Prafu,inm Code, and to, license
-
in full force ;nal elect.
Lee
Date.eclat ue.«
#
HEATER
'LieC.al
WATER
ARCI rri.CL"S DECLARATION
'
I cul mood ;uy plans nh;dl bin iced .e public muc d,
-
Llcen.od 11nticsslunul
OW NER-BUILDIilt DIiCLARATION
I hereby 41irnh Ihat I ant ucmpl from the Coramcmr's Lie ..se Law Int the
l dlnwing too vnh. (Seeman 71131.5. Bo,incss and Post,smm Code Any city or tummy
'
which rtgairee n permit m oa lmct,.Ileo Improve. demolish, or repair any structure
print. it, i...cnce, also s ireslhm applicant forsuch permsm file aligned ...einem
Sq. Ft. Floor Area
Valuation
that he ishamwdpmntumtit) the pro,tion. of the Contractors License Low (Charter 9
(... unmoving with Scudo. 7010) of Division 3 of the Busincs and Profession, Code)
or that be is exempt thcodronh and the hams for the alleged exemption. Any violation
of Satin. 7031.5 by any applicam for a permit ,.&B as the applicant m a civil penalty
APN Number
Occupancy
of not mom than five hundred dollars(S500F
❑ h as owner of the po,s rty. or my ell with wages as dw r ole compensation.
R ired Inspections
will do the work, and the ahawmm its not intended or offered for -le ISa. 7044.
Rations and Profession, Cale: The Contractor'. Liccnm Law anes not apply m an
owner of pmpeny Who builds or improves themon, and who does such work himself
or through his awn nnplova,, provided that such improvements art out intended or
offered for .sale. IL however, the building or improvement is sold within one year
502 — FINAL PLUMBING ENERGY
c)nhpletiun, the owner-builder will have the burden ofproving that he did not bind or
GAS TEST
ntpm,fmpurl•:,cofmic.).
e
506 —
❑ 1, as owner of the powny. am exelaauely contracting with licensed c.mranors m
507 — FINAL PLUMBING
construct the project (Sea. 70,14. Busin sv and Profession% CNet) no Commelar'x
Lieeme law does nm apply to an owner of property who builds or no,owes thereon.
an who codicils Ehr such projects with a rnmraelortal incensed purwam. to the
C,Louh s, Li... so Low.
❑ I uta unapt under See .B& It C fm this m:onn
(lwntt Date
WORKER'S CONUPIASAITUN DECLARANON
Ith Poll 6J Pei nv:
II lyl'I 1 1 Ity fp rl Y all
/
olh d 'II I Certificate IC IDI,%If' f Worker's
an p, t provided J t' by Sent 378) f the ].am,, C of fill the
`til
perfomnnce of the work hr which the pernl is issued.
O
❑ I hoc and will maintain W'ader's Conhpen.mion Insurance, as required by Section
3701 of the IaMa Code, for the perfommncm of the work for which this pinnal is
wed. Mly Workers Compcnsaion Insurance carrier and Policy number arc:
Carver: Policy No.:
CERTIFICATION OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This onion neral nm W completed if the permit is far one hundred dollars
(Saw) or It,,.)
I eenily that in the performance of the work fur which this permit is issued. 1
shall not employ any person in any manner sit as to become subject to the Workers
Compensation laws of California. Oat
Applmnm
N TICLTOAPPLICANT:ILcuter making thi% CenlLcam of Exemption, you should
bec)nm subject to the Worker's Com,enaaion provisions of the Labor Calc, you into
Ibnhw'nh c Fly with such provisions m this Peron Yhall be deemed revoked.
3 CONSTRUCrlON LENDING AGENCY
,
I hemby td'Iiran that them i. n unns... ctlo. leading agency for the vidom,re,
,
"I 11,c work Gil' whieh This perntit is'naucd (See. 3097, Civ, C.)
Lender's Nc le
Lender', AJdtcs
i1 «nlfy thus I Musa null this ;mplicwinn anti stair that the above in nonunion Is
correct. 1 agree m comply with all city and county ordinances and sale laws inching
m huildi.g cor,wnicn, and o rchy amhome represenotivm, of this city to c.mr cpm
'
p the thmvnmendoned Progeny for inspcctiun pur Poo,;
(We) agree to %ave, indemnify and kap harmless the City of Caperton) against
liabilities, judgments, arms and expert which may in any way acerae against said
C City in mouse,ema nt be gmml It, of this perntit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
y'
SOURCE REGULATIONS.
Re-rooks
Signature of ApplicanUiCaten r Ilam
IIA%ARDOUS MATERIALS DISCLOSURE
0511 the upplicondn future Wilding occupant sore or handle lacteal material
Type of Roof
a%delined by the CuNi inn Municipal Code, Chapter 9.12. and the Health and Safety
Code. Section 25532(a)7
0}yc' ON.
All roofs Shall be inspected prior to any roofing material being installed.
Will the applicam or I mare building occupant use equipment or ties ices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit huurd)ox air conmminums as def nod by the Ray Area Air Quality Management
all new materials for inspection. Applicant understands and will comply with
strimr
❑Yes 0N
all non-point source regulations.
I have read We harudaus tnnmriah requircownts under Chapter 5.95 of the
lifornia I leallh & Safety Clale, Seniums 25505, 25533 and 25534. 1 unacnmuJ nut
,
ttle bonding dorssol ntroadly looc u mmun, that it is my responsibility m nottly the
71z;1'
occupant of the mgairtmmndv winch into he met prior to isatunca or a CeniBmme of
vpa°cy'
Signature of Applicant Date
All roof coverings to be Class "B" or better
.gots hale
wnn armanhari.ra
OFFICE