01080100 Cl BUILDING DIVIISIONSINO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21956 OAKLEAF CT RESCUE ROOTER LLC #170 01080122
OWNER'S NAME: APPLICATION SUB DATE
MENDENHALL PAULA V 1479 BERGER DR 08/24/2001
( (408) 287-2165
/ PHONE: SANITARY NO. CONTROL NO.
C ee Z ARCHITEC(ENGINEER: BUILDING PERMIT INFO
K¢C•.0 BLDG ELECT PLUMB MECH
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Z4z LICENSEDCONTRACTOR'SDECLARATION Job Description
i.4 w ciion7y X)"d Dh lanallrenx nine pmviai°ns n( Skg1,.9 dan,license REPLACE WATER HEATER.
y(_ wish full faire an Ief Divasiun 3 al the dminers'ty�, ydC:mJ my license
yz_ ismfauromeaaeerred. YI Ir (75 GAL WATER HEATER)
reC a u Lire se Class Lic.M
Gate Cnnlmmm
i 3 u.v ARCHITECT'5 ECLARAVION
g I understand my plans shall be used as public reroNa
i Epp Licensed Professional
esOWNER-BUILDER DECLARATION
f—' 1 hereby atfinn that 1 am cnempt from the Conwcer's License Law for the
t z< following reason.(Section 703 I.S.Business and Professions Code:Any city or county
3 ❑ which requites a Permit to contract.alter.alter,innards,demolish,or repair any structure
a3. prior to 1 Lw requiresth PPI nt lw such potmno rile a signed statement
that hq is limmiedp : t in the provisions ofthe Contractor s Liccnx Law(Chapter 9 - Sq:F[ F1oonArea,tea' -.f e aluation
(commc g.'m Smbn]1100)ofDivi:un3nl the Business ana Rm
pfcssa° CWq l.t}.\ 1ti-\v : lY:\ L. ..N .5.._
or that he is cnempt therefrom and the bays for fle alleged esempunn.Any violation
of Section 7031 5 by may applicant for a remail subjects the applicant 10 a civil penalty
of nodmieflsn'me hundred dollars(S500) APN um ej Occupancy Type
❑1,as uwna of the empenY,or my employees with wages as their sole compensation, iFNERGY
will do the work;and the structure is not intended or offered for sale(Sec.7'44: o stn u:
Buimesi iumPminsions Code:The Conlmnor:s License law does not apply 1°an 506 - GAS TESTequired Insgections
owner of pmpenr Who wads or imrm.ea Ib[reOn.am who doer aae work himself 507 — FINAL PLUMBING i
or through his own employees.pmm
vnded that such improvements arc not imeaded or
offered for talc.If,howvrma the building t is sold within one year of
a -- '"' - - '_' "'
maplaion,the owner-winter will have the WardenWardenof Proving mat he ane not was or
impm.e fw puryose of sale.(. 1
Constru
_ pence Xam Businissadfomctmg withvdc:)Th,Comormnm
ima.taw the rrojm(See.]BU,msam o and Professions ild, r The ve,fa to n, n D.,, r,
License Low does not apply m an owns with
a com who wilds se improves(hexon. 1
C. omru,,'o"mecs for 1 with a commetm(al licensed pursuant m the _
rend who c such.pro'cas C
C 'x License taw. fIFIN �Ir��ir®...
❑Inas excmPl under Sec. - ,B&P C main,reason 1
Ownrr. .: Date' SEP 0 5 2001
WORKER'S COMPENSATION DECLARATION
I hereby aRma under penalty of prijary oz of me following deelaretionr.
❑ 1 have And will maintain n cenifcble'ol'consent I°scIrmwrc far Workers BUILDING
C......inn, as provided for by Section 7700 of the labm Coal, for the
performance of the work fm which this permit is issued. ,
❑1 hale and will amity-fin Worker's Cninfar o ohlnkurrom,as derfored by Section
37M f theLaw Code farthe pmf on e f thedrA',f which this petmn:s
.sued Aly A 'Co 1 .�mrc and Policy umhe m
_ / �]
none
Il. It Policy N � 's C / D'
V .CERTIPICATI N OF h%EMMONFRMMWO KERS- "' S. I 1kL s 1 l.N*1 4 . p�"Cjsj;
" 1 COMPENSATIONINSURANCE'
"f tint:auJnn2eJnmleemnpmtedtrm=cerma .n,r^newnamaaellam :,P•, .realI. .; O�.atFa'a.• f�.r
(510(B or less.) .-
. .IK, _
rM1all'nmcm Yi
, anrot _ ... . �..".._...�......._... _ ..-�...
I'Icenif'ihafn the Rormantt'nfthe work for which this p<rmitis issucd.I
p Y Y,pen 'm any twrincriw us to,bceane suM1lcn 10 rhmWurkeri
"ComPc , unlaws ofCalifornia Dte'
.App( 1
NOTICCTO APPLICANT r Com nsati haCesions of
pt n °uu mulct '• ''1'• •'a """ �"
Q Oti adrovi subject apl n she Worker's Compensation provisions rel the Labor aev.k you mus(
foahwilh complybilti inch provisions.,,his pemJt shall he named revoked. '
F-W ';` CONSTRUCTION LENDING AGENCY - -_ - -- - "" — ISS ,
` 'I h,m1by offirmi mad 6arammlim Immor,irgenc,for the perf'mtance
of tw�worlk for loch this perm I is issued(See:3091 C v,C) I _
lY Q Leader•:your
am '
�..� Lknder's'Addresx,
I e niry twt 1 have read this applicmion and si a thea the°woe informmiaa is
coirccl:l agree to comply with all city mW county ordinances and slate laws relating
t°wilding consuuction,and herby nm6mim representatives of this city to enter upon
�-R7 IheaW,e"mentioned progeny for impeaion purposes. •
(, 0. (Wc)agree to save,indemnify and keep Wordless the City of Cupertmo agaimt
-VJ liabilities,judgments,costs and expenses which my in my way acerae against said
City indonxqueneeoftwgmnting.fhh"peimit. ' I "
^_' APPLICANT'UNDERSTANDS ANDWILCCOMPLYWITH'ALL'NON�POINTr Issuedb Date
% 'OURCE REGULATIONS'..", Y'
gni t rnrnreanve 1 as - 'Date. - Re-roofs
HAZARDOUS'MATERIALS DISCI OSURE'
" WnatcaPpwanl f d wldg panto onhandlahaaalloasmmatal. Type of Roof
u def ed by the,Cupcn n Municipal Cad Chapter 9 12 add theHealth and Safety
g ,` ,3 s r _ , i,r*+I ,r ;• '. I I I `I'
code Section 8543Ha) ] i, 1 }
Y8
❑v A p'N _All roofs shall.be Inspected prior_to.any.roofing materialbeing.installed. ._ ._.._ ..
..r 3Yll thea (team orfuwrcwildin occupant t or devices which' v
pp goe pan ryaipmcn If a roof is insialled,without first obtaining an inspectioti;'Fagree'to remove
mit WAnkcins art marourairmas a,defined by he Bay A Air Quidity Management
Dial all new materials for inspection. Applicant_understands and will comply with
,) OY ON. r� �. _ all non-point source regulations;,4111
4�' l1 have"ad'the haan tar,mi we Tis requt¢ments under Chapter 6.95 of the
Qslifomib Health 5'Safety Gide.Siouan...25505;25533 and 25534.1 undenwnd the, -
ifrhebuildingdzs nm currently ha,caxnamnhatilismymsp nsibilitylonolify he
ottuparil f ttic nequiremcros hi must be asci prior to issuaze of 5 Ceniricue of
Signature of Applicant Date .
r� roof coverings to be Class"B"or better
O'n ° auth°riuJ agml"
Data.. All
.,. ..,. .....:. .. . . ) OFFICE . . .. _.... _ .. _