00090104;I uLDING DIn11I°N v PERMIT I CONTRACTOR INFORMATION:
BUILDING ADDRESS:
OWNER S NAME
THONG:
w O O ARCHITEC AINGINEER:
.e.0
u
fL6
LICENSEDta CONTRACnder's UECLA RArION
✓ - 1 hereby alYinn flim acro licensed under prnv'ninn%m Cnaprcr. (ainmrencing
F�t� who section 7(xw)nnliyi'nnlnnhe Bndnea%n,td rmr�%%;ons c:µc.r�J'jty rause
i, In full forte anJ21Y'esrt� Z 1 1
z m ¢ Livens, clan mit
VV Lic. x
XX O ad O Dole Cif ori k�.���- Commove —
— I VV 1 ARCHITECT'S DECLARATIOI
t_LLO� 1 made ....J mypl shop the used apublic N.
ve
wy00 LiletroldP I.: 'I
or OWN (It BUH A:k DECLARATION
ARATION
+l= Ili hyfil thinIi Itl the C na,f License Low lorthe
balloting wood. svoi , 70315 H on.. J ]I f .. ns, Cad Any city nr county
es,F. F o which requires a recruit m can.amm, aller, improve, Jcinclixh, or repair any fibulare
3m p -do, to in is.%uaare. ureqsupcmm a
lsouiies the applicant ch til file %igml loolosent
e.that he is teen: cl pursuant to the provisions of the Gmtr¢mcs License Low (chapter 9
hommencing with Section 701w) of Division 3 of the Business and Pmfc%sion% Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
of section 7031.5 by any applicant for a Permit %objects the applicant vat a civil penalty
,,fact mate than five hundred eolhrs (55(wL
01, m own,, cl the property. m nay employees with wages a, thou sole aatnlenxteiou. .
will Jo the work, and the wlmaure is urn Intended or I. Briar! for sale (Sec 70iA,
How and I'nde% ar Gale: The Contracture h.. ... - Law does not apply to a
orvr of property wnn hrllds or improves metcmt, and who does Loch work loosen
through his awn empi psorded that such improvements are not intended or
offered for sale. If, however. the building or improvement i% Sold within one year of
inpletion, the mvma-builder rill have the burden of proving that he did not build or
mprove fix purpace of sale.).
01. us owner of the property. am cxcltsively contracting with licensed cotnneun%m
mtmet the proven (sec. 7144, Business and Proe,ions Core:) The contractor',
I cs e Law doe ve nrpl,,, aow
n owner of progeny who haikk nr....prism dtcrcutt.
red woo ontracd for -ch projects with a mtracda(L) reunwd mfr aunt w the
Cnnoucna s Liver, Law.
01 :nn exempt ander Sec. , li of P C for this resom
Owner Date
WORKER'S GDM PENSAI'ION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 I have :nal will admain
n Cenilicate of Convent,, oelf-insare liar Worker's
Cmnpnuntivr rev pro6d,dInt by Scion 3700 of the Labor Gal, for the
off ... notice of the work for which this permit Is i,etred.
01 have and will armawin Worker's Comrynwation Insurance, as required by Scction
37M of the Li bur Core. liar the performance of the work for which this permit is
issued. lily Waders Compensation Insurance currier em q' ber u
t-amier:6(A&Vet"1 Q" Pehey Nn.— � tun �Ki( k
Cl2R ['I FICAI ]ON OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be Loo plca,d if 111, pernit is to, ,no hundred dolbsv
(S 100) or Ins.)
1 cenify.thal in the performance of the work for which this permit is lower, I
.shall not employ any person in any man er or as u, become .subject to the Workers
Compensation [if 'a. Us
npplicum
NOrICGT I M" l aper making lhir Cenilica¢ o Exmnptinn, you shnulJ
he<nmc subjecun tit r.r'v Compensation provision% of the Labor CrAc, you mu.a
Oforthwith comply with suchvprovisiun.% or this permit shall he deemed revoked.
CON Sri RUCTION LENDING AGENCY
aI hrrcby draral that mere iv a conswcGon ,"afro, agency ronhe N6 ... ravoc
W of the work for which lo, Lcanif is Issued (Sec. 3097. Civ. C.)
6. Q Lendef: Name
Z 1<ndch Address _
U C I cmHy that I have beat this application and Smte lbar the above infurcurimn is
Il. P ev rase,. 1 agree to comply with all Cly and coutr y oNinonce% ad slate law%relating
U ,,building faromeIan. and hereby authorize repm%entalives of this city ea enter upon
r the ahove-mencond proleny bur inspection purparsu%
G (We)agree In Java l ndninniry and keep hurrnlcwa the City of Cepeninn against
nFi tp liabilitln, judgtncnts, mmx crud caponsee whish Int y in any way aurae against said
U Z City in eonwgaonce of etc'noting of thlx perm.,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Sigtumm of ApplicunhCommnur Date
HAZARDOUS MATERIALS DISCLOSURE
W ll the applicant or future wilding occupant %lure or handle hazmdoux returned
as defined by the Cupertino Municipal Core, Chapter 9.12, snit the Health and Safety
Code, Section 25532(,)!
Cl Yes 0 No
Will the upplilrel or I'umrc building I'r""omt rise esrylpmenl m dd...cx which
umit Imeardnns Air conunmeant, us defined by the Hay Area Air Quality Man:agemant
ixvmn
❑Yes 0Nu
1 have read the hrmNuus materials requimnnem% uosler Chapter fi 95 of the
California Health A Sure, Code, Sections 25505.25533 And 25534. 1 understand that
it the building Joins not cu catty rose nun0 ohm it is my responsibility to notify the
occupant of the rcyniair is wM1i'h must he nret prior to issue. ce of r Cenificme of
Occupancy ��v—
Owner or auB,onted cut Date
PERMIT NO.
TIS WAT-I`I" .J j`Ir 00019M104
APPLICAl ON SUB DNI ITT
1.764 NAT-TON1A1 1A/rt 100
SANITARY NO. CONTROL NO.
BUILDING PERMIT IN1.)
BLDG ELECT PLUMB N1EC11
UJ 1=1 1=I -=I
Job Description " .
REPLACE 50 GAL GAS WATER HEATER
Sq. Ft. Floor Area Val w on
APN Number Occupancy Type
'i 'i squired Inspections
Issued by:
Re -roofs
Type of Roof
106 —
SEWER
R• WATER
202 —
UNDERFLOOR PLUMBING
301. —
ROUGH
PLUMBING
302 —
TUB &
OR SHOWER
502 —
FINAL
PLUMBING ENERGY
506 —
GAS TEST
507
— FINAL
PLUMBING
Date
All roofs shall be inspected prior to any roofing material being installed. -
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant
OFFICE
Dille
All roof coverings to be Class `B" or better