01070108 TINO
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CITY O
PERMIT
I ' ER . TRACTOR INFORMATION-
BUILDING CDIVISION --
CON
THSKY SQ......._�:._._.�..._._. —_ - _WA -HEATERS
R ' _, r PeRMlrlvo .,, ,8 .
TER_HEATERSONLY . , ,.___,_ ,0.1070.s1u08_._.. _.
y `ff.fWtXfG ELEANOR S 500 AIRPORT BLV AbrycT[tgN/$Abel
PHONE: (415) 349-3747 SANIITARYL NO. CONTROL NO.
G et.z ARCHITECTIENGINEER: BUILDING PERMIT INFO
UW O BLDG ELECT PLUMB MECH
a U - - L._J L IJ I_l
,�„Z 'LICENSED CONTRACTOR'S DECLARATION
O Z=o I hereby affirm the I am licensed under provisions of Chapter 9(commencing REPLACE WATER H�r�{j�''tn� Speri [ion
F,S�w with Section]BOB of Division 3 of the Business and Professions Code,and my license ""+ •`•P
a E; is in mu force and effect. (40G GAS WATER HEATER. )
z a Liccnu Class,
Lip.a
i
st U Data - Compact.,
w t s
ce 3 ARCHITECT'S DECLARATION -
O 1 understand my plans shall be used as public records
t ce
t
neM 0 Licensed Profes.siunal
OWNER-BUILDER DECLARATION
e I hereby affirm that I am exempt from the,Contractors License Law for the
a following mason.(Section]031.3.Business and Pmfeuions Code:Any city or county- - -
Y C which requites o Perritt.comrsin.alter.improve,demolish,or repair,any,swnum
c, Timeliest"issuance,ablaiince,iiiestlac applicant ch lxrtmuo rl a8rcd mmmem. - - --- - ----- - -
tbar he nit kap mlmt .he Positions' fth'Cgtractor e. La (Copt 9 S Ft. Floor Area ..i. _ - Valuation_ _.
(co g.with Sect n]00016f ON 3 f the Brame,, um P fe C ac) `l' q'• ! t \ '{ •.,"i n
or that he s exe opt themfmm and the bat's.for the alleged ex mpann Any violation - 3 164 O O 5 0 :!O O
of Secron 7031:5 by any applicant for a permit subjects the applicant to a civil penalty
'.ofnot mom than five handreddollars 5500).' APNNumber,,: , 1;+,- °.' Occupancy Type"
_ _502_ _. TINAL-'PLUMBIN --ENERGY _...—_.._
. ' v L d owns of the ad she Y-m'mYe is o t In with Wages as theifor sa['(Sec.sation:
will dp'theworkland'Ne zwcturc is'nos imendeJ'or offer.)for sale(sar]t]H, 506- '- GAS TES '
•Business andPrefeesions Cale:The Contractor's License Law does not apply t.an T(2equired Inspections '
owner of prolrcrty Who builds or improves thereon,and who does such work himself 507 - FINAL PLUMBING
or through his own employers,provided that such improvementst tended or
"Wimp]formde if how-er theholding rip coca's ler withineyes of - --'_ _ -..... ... .. _ .. ._. .... .. .r -_
6
ampler an,the owner buil Wer will have Ne burden of proving that he did not build or )
improve for purpose of sale.).
_ -- — — — .._.FIIVALE�-- — —
O 1,as owner of the property am exclusively contracting with licensed contractors to 1
- -
construct project(Sec.](HJ,Business and Professions Cei The Contractor's
License Law does not apply to an owner of progeny who builds or improves thereon.
' and wC,nmho cv License Law, actors)licensed pursumt.m.the. 18-2001 ...... .. ...._ .....
❑lamcx,tracts for.such. comp .... ._ .._._. ...._ .....__. _ __-
, 11
.. .: aha hop SEP "-
cmpt under See ," :B&P C for hs moron
Owner Date:.. tiBUILDING
WORKER'S COMPENSATION DECLARATION
'1 hereby affirm unacr,pemlty of Perjury one of tbe,following declarainns:
❑ I have'and will nuintzm"a Certificate of Comctnlo self-insure for Workers, -
.r Comperroun n, as provided fro-by Section 3700 of the Labor Code, for the
_- performance of the work fur which this permit is issu<J. - '
❑I have and will maintain Worker's Compensation Insurance,as rcquimJ by Section
37M or the Labor Codes for the performance of the work ftir'which this permit is
issued:My Worker Compensation Insurance carter and Policy number am: s _ - M,•,�
C,n I 'Pol Y Nn - J.,a V:v a ... 11...1._., _
!.'CERTIFICATION OF EXEMPTION FROM WORKERS; - ' s .t^ •'f 2 t`
COMPENSATION INSURANCE ,
(Th s seamo need not be rompleted if the Permit is for one hutWmd dollars
-' -(8100) less) . . ,rrl
.,.
M> l certify that in the perforpoince of the work for which thpennon is issue .I
shall not employ'+^Y.P m in any n5 as tobecone subject to die'Workers'
pens non Lau,of Cabfomia.Dae
ApplicantTO APPLICAM'.ICafmr ttukin6 anis Cmdi
-NOTICE tate of Exemption,you should t'
bceome subject the Workers Compnnsation provisions of the 15bbr Code,you mit
mij
Q O forthwith comply with such previsions or this pert shall In N deertsrevoked.
Z
. - _ --
-_ ... ._ ..... .. . ..... _. ...
'CONSTRUCTION LENDING onj. '
.a[> the
work
for
which the there isamued(Sic, lendingagency for the)performance
1<nder's Name
f$cc.tm],Civ.C.)
al fxthe work for which this tis issued ,. _ .. - - ..• ... __ __ ._. . ... _._.._.__ ___ . _.. _.._ _ __.. _._. ._. -
Perri
d.Q 'rider's Name v,
V C) Icenify that l have read this application amt state that heahove information ist
Wo Est correct.I agree to comply with all city and county ordinances and state laws,elating!
� [) do bu JJing toneretion,and herchy amM1orim reprpsentmivcs nl this city to enter upon, l
Ah M t !ed property f 'pen /.f � /�
[teal IsteldgindemnifyonJk<iho Ittv tan City rearm,Cupertino
aaierg'nm
-00 liabilities.judgment.atot d expenses which mai in any Y against said
U Z City in coup"uence of thic granting f this pe u
APPLICANT UNDERSTANDS AND WILLCOMPLY WH ALL NON-POINT A� hr<, _, Date
SOURCE REGULATIONS RIssued by:
.r 5 8 .t t AppbcnnnC t t ct _ F Dam Re-roofs '
l k HAZARDOUS MAIFRIALS DISCLOSURE
Wlllthc airdicarit im futures .mo
buildingpattorh dl h' Nousmterial .Type-Of Roof.
as defined by the Cupertino Municipal Cove.Chapter 9.12,and the Health and Safety, -
'caska Sect nn 25532( ). , ; s!r.• - v 3
riyes' o" t All roofs shall..be tnsp'ectedP nor to,any roofing material-being-installed..-.. _
„ Will theapplicant future building occupant q p tp devices h h' If a roof is Installed'without first-obtalmng ariiinspectBon,Po5gree to remove
enth rl 'aiV imparrinnnasasdefndby theay Area Air Quality Mu engem t'
'Dm ct - - nm
- all new'ma[cals'forspec[Ion,- Apphclntunderstand_s'and will comply with "-
..
❑Yes .-{I. Elicit' 'p,l all non-point source regulations. .
' 1 have He rear the h:vardws maenads0.2 533requirements under 4.1 un 6.95 of the
C.lWitte building
Heahn&of Safety
exurCodc aveatena550hat no,3and2553y.luy_t.a it the
ifthean,ongdoesnotcurmm�dyhateatenant:the it is myscspomibl ernotify the
Oba P n of the -remenis which moa be ma to issuance of a Cenifcme of
°"" � - Signature of Applicant Date
"^ •T'' - ,Dae -- _ . . Class"B"-or better :.
N
owne,pr aamnnxea aFenr: Al] roof coverings to be
...: L - - -
::: ._ -OFFICE. _ . . .. _ .... _ . -.. . .. ..