00120066 cloi .,,til'1'Y OF CUPER'I'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RUB.DINGAIID IS�11. PARLF_TT PL JUST WATER HEATERS 14th111�N°9J012006r,
OWNFR'S NAME' APPLICATION SyB.f),3'rE�c'�IIt•10
CARY GEE 1.7F4 NATIONAL AVE ci
'IIONI?:
(510)293-9901. SANITARY NO. CONTROL NO.
0-7 ARCHI'I'ECl'/HNGINEER: BUILDING PERMIT INFO
w O BLDG ELECT PLUMB MECH
LICENSED CON'TRACT ORS DECLARAION Job Description
�_ I hereby affirm dial I am liaeiri under,rn.f n of Chapter 9(commencing
0 C with Section 7(XXr til' on
Dovrvi 3 of the liminvexund 1'ndn,,:nns Code,and mcn.
y Iiu .
=Y—�
is in full orientalorientaleffoo.
ce2 License Class Lie,x
O°U Date Contactor REPLACE 50 GALLON GAS WATER HEATER
N ARCHITECT"S DECLARATION
C t=' I.,ad...lianimy plans shall be used as puhlic record.,
w i p p Licnl,oA Prnles,ionul
OWNER-BUILDER
exempt hour
lire Come ON
m'9—'w I hereby affirm that 1 am..nope Both tb:Contmcmr's Lican.a law for the .
C X a following uires a er ainn 7031,5.Ilmloa„and Prt:lmsio l Cndc:Any city or acture .
i3S e which requires a e,alsom Lim,,m,alcor.Improve,h permil1 fi repair any m,acmrc
m that hn%fits ctaancgalsoayt)he csov,orhc im Itire C,nammtit Licessia.(Chcomem
that he I% sedpSerinmthep fDivisinun::Cootmcmr,ucemedes,mr,Cor) Sq. Ft. Floor Area Valuation
(comas he is g with Sermon i and
a Division 3 of rhe leged x and Parion.Any vi Cody
or Ilia he is exempt therclmm.vW the ha,is for the xllcgcJ cxenlption.Any violation
of Section 7031.5 by any a,lartm for a permit ulnest the cloricunc to it civil penalty
of not more man five hundred dollar,01500). APN Number Occupancy Type
O Lav owner of the pmpeny,or my emplusee,with wi it,their sole cmnprovtion,
w do the work,and the structure is not intended or offered for sale ISvc.Tai.
Bu,mc„and Pmfcsxioms Cnde:'Ihe Contractor's Liceno,Law dues not apply In an " `'' - J• Required Inspections
owner of property Who Wilds or improves theretm,and who does such work himself
through It"awn srnplo".e., provided That soon impmvemenw are nut intended or
oamed fa,v1e.If.however. be homing o,impro,cmevt is,old within one year of 502 — FINAL PLUMBING ENERGY
:�Impletion,the owner-h tildcr will have the burden of proving chat he did not build or GAS TEST
Ipm,e ser par„we oaale.j. 506 —
[_-1 1.a,owac,o da,prolwny,an-clu,ively contracting with licensed contractors it) 507 — FINAL PLUMBING
Lraauel the p.),,,,(See.7N4.Bolcom,and Pmfc,,:nne Cndnp'The Cnmrmho',
iecaw Law does not apply to an owner of property who Wilds or impm,es then,.
Bad who contract,for,Bch Amina,win a contract ,) licensed pursuant to the
Comowhi Liccnw Laos.
❑I am_rac,a under See .B dr P C fnfick.-ir
00.
wner hale
WORKER'S COMVENSAI'ION DECLARATION
1 hereby affirm under penalty of pcijury one of the fallowing declaration,:I have and will maintain a Ceniliaam of Consent it)sell-inwrc for Worker's
as provided for by Section 3701 of the Labor Gale, lir the
Performance of rhe work fur which this panni)is iducd.
Cl I L",and w'if ne:ioutin Worker's Cnmpemauon bu...a n:c,a,nNim.ed by Section /
issue of the Labor Gdm for then Insurance of cr work lir which tare permit is /
37M(id.My Lalsr's Compensation performance
of the
Policy number are:
Cnricc Policy
chINIFICATION OF I!SEMI'I'ION FROM WORKERS'
COMI'GNSNINSURANCE
INSURANCI? O
(I ho.metiun nmd not he con...eod.1 the per nit i,for one htmdrcd dolhm.
of Off or lost
I walfy that in the rdri mrale or the work for which 11n6 retail is Issued.I
shall not employ any pe sem in any moaner,o as B,become mbjea In the Workers'
Gm:pvnerion Laws of Calihnlia.Dane
Applicant
Nol'ICE TO APPLICANT,It,after musing this Cenifcatc of Exemption,lou should
Ohecembi"Ito elm Wmk",Compmoifocl Inovi,ionsof the Labor Coale.Your l
nmforthwith comply with such pnrvisiuns or chi.,pernic shall Is,deemed rooted.
rte—. V_i CONST RUCTION LENDIN(i AGENCY
1 hereby affirm them them is a construction lending agency for tb:pie fomsantt
of the work toe whish tbi,ry.cr int o iomd(See 3b)7.CIV.C.)
4 Q Lender's Name
Z Lender's Addis,,
U I cenify that l have mad chivpplication and,mrethm the above information is
I,. F.t cnncet.I ag,,e n:conq.1,wilt ill si y and county mdmancea,and stare mu,relating
U to holding etlrowetion.and hereby aathorlre representatives el this city m enter upon
the above-meminned property for iispe,ion purrylscs.
F y
(We)ugmcmsave,Inde,, yand keep hanale,,tire Cityof Capenino against '
CA liabilities,judgments,costs and expenw,which may in any way weruc against said
U Z City in wqucnce of the griming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
SOURCE REGULATIONS.
Signature of npprcanl/Contmctor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W,11 he apprma:n oft mture building oc,o,vion atom or handle ha.,:nmu,:I:atedrd Type of Roof
m defined by the Cupertino Municipal Code.Chapter 9.t2.and the Health and Safety
Cade,Sector 25532(:)'!
0 Ye` 0N All roofs shall be inspected prior to any rooting material being installed.
Will lo,appheantorfanrehtdldins"eeon: ...em,irvnentt':de..ee,wrich If if roof is installed without first obtaining an inspection, I agree to remove
nim baumom air contnmmann a,defined by the Bay A=Air Quality Managooenm
ovaria? all new materials for inspection. Applicant understands and will comply with
0 Ye" 71 No all non-point source regulations.
I have read the ba.edon,msaerialy mgniranan,ands,Chupmr 695 of the
California Health A Sala,Cale.Sections 25505,25533 and 25534.I undmand that
it the hui ding dives not utrently have a commit,that it is it,re,lumsibility mo notify clic
occupant a1 the mr ineneas which moa he mac prior civ..amnec of a Centile,of
°ca"panel` Signature of Applicant Date
Ownoo,amhon,W ages, Date All roof coverings to be Class"B" or better
OFFICE