01010121 CI out of GUDPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
7536 PEACH BLOSSOM DR BUDGET PLUMBING 01010121
C?ffWAME: APPLICATION SUB DATE
HORTON 28695 ROANOKE ST 01/30/2001
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PHONE: (510) 264-1113 SANITARY NO, CONTROL NO.
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ARCHITECfIENOIN . BUILDING PERMIT INFO
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u"i u."y;;i 1S-g.• l.r BLDG ELECT PLUMB MECH
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z n i LICENSED CONTRACTOR'S DECLARATION Job Description
o zit I- Ihercby affirm thmlnm of
Basins pmvisiofssins Codr9(commencing REPLACE WATER HEATER
F s3tm with Section ad affect.Division the Business etM Professions Code.road my license
6 x S is in full force anA effect.
6.,M V License Class Lic.a
KK Date Convenor
3 0 r ARCHITECT'S DECLARATION
C y'm j I understand my plans shall 6e used as public records
„N
p p� Licensed Professional
OWNER-BUILDER DECLARATION
tkii '4 y I hereby aRusn that I am exempt from the Connector's License Low for the h
Z'a following reason.(Semon]IIJ L5:Business and Professions Cock:Any city wcounty - 4�j O O
O which requires a pemt t t ,v teen,alar,improve.demolish,m repair any nrunure
Eu 3.$ poor to tsnssuance,nl q res the applicantfor such perms tn fleosigned statement - Valuation
Neth!1 I cenud pondom t.the provision of the Canwnoh Lmenu Lew(Chagas 9 �`,s,pt �s� C�a�.ay♦ < t t.
(cotnntencmg nM1s uon]t30pjvofDivision3ofthcausmeasagdProfess��tsCod<I` 3,6,'CJiL;7.3L9 ?i�I.
or that be t4 exempt therefrom end IM1a bas s for the all
dr<mpnon.Any violmian
-of Section]0J IS by my applicant for a pertnit subjects dre 0,'em so a civil penalty'
P.Gnot mom.than five hundred dollars(130(d 502APN YtO PLUMBIN ENERGY Occupancy Type
❑1,asmarm,ofthe progeny..,my employees with wages as their sole mmpensalm, — Mpg,{ m.
will do the wark:and the'swcture is not intended or offered for sale(Sec.]04a: 507 — FINAL Piwray}�i ItDtspection5li' ='•' ' '
completion,erurshe ownerbuildcrwi llhavetheburdenverm-ingt h did not but r 518 — WATER HEATER
Bu'sin sand Professions Cale:The Canwcmr i License Law a apply to an
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owner of progeny Who builds or improves thereon,and who does{ftj
or through his own employees.provided that such impmvemems I(�d not In e d r -„ --
'I forale:wneoletildethebuildingerurden oetnenineo1Nwithin one f - - -
improve for purpose f sal ) '
;41 es owns ofthap pony am eulunvely camracnnrev
g wit ..sed contras
conawnlNe roles ISe 1614 Business antl Profeutons a Ca t" --(o ..LF s10 r
p s '
lacenu law does nm apply to an owner of poperty who bu Ids -
::. end who contmnslor such pmjecfs with..conrnecto .heensaf p rove _..__._ .._. _.___ .. _.____..__.------- ___..._.___.___._..__.._...__..._
Convectors Licene Law.
. '_ ,:' r. ❑lam exam tundcr Seu'" C for this rcaspn
P : .. ..t. vrt.
_ 'Owner Dore
WORKERS COMPENSATION DECLARATION
1 hereby,Mm oder pc,ahy of pc J yr one of the following drearati... -
❑ I h ve nd 11 to.tam a C nifi at T Cement to self insure for Worker's i
Compensation. in pro ded for by-S n 37W of the Labor Code, for the
e. 'performance of the work for which this permit is issued.., .
❑1 have Snd'wi11 mulmain Worker's Compensation Insurance,as
rcijuirW by Section
- J]0sum,0 of the Iabar Code,far the}ierformance or the walk for which Nis pertnii is
I RTIFICATION OF EXEMPTIONer nd policy,cy number arc:
` { ,:.. .:
✓ ._ .:._
''GmerMe WCE rsC vni to l`nsvnnce sem FROM WORKERS., L' t. lt t
a
Polcy No
1 ..., _ COMPENSATION INSURANCE
'jndS.enidn oeed mit he<umplctad if the permit is for one hundred dollars '
1 certify thing the r(mn arc .n the work forwhichthis permit a ped,1
ssh II n t d to vs soon in a. manners is to become subJm m the Workers'
'Cmmpenpauon aws of Cnl torn a.,Dme
NOTICE TO,APPLICA If;oOa making this Certificate of Exemption,you should '
z become subjedi to the Worker's C pe or.n pm bions of the Labor Code.you mist
Qt a comply h such provisions this Permit shall be deemed ked
7 fotthu th cam I with
:F. t Sf-sk ''" CONS ULTION LENDINGAGENCY. -
'a sr b 1 hekby idRAn thin theme s e con te<u I digg g ncy forth perfoiinanee
of therk for hich th P t .tss ed(S<c 3091 Ci C)
az Lender Address GT '..r g..n.
ccnify iltm 1 have read Nis application and state that the above informed..is
W nr'rect.I"'Ify gangly,with all city and county ordinances and state lows relating
Q.-- mon'-siI"'mistrordibi and he rt by mullion.representatives of this city..enter upon
0. the above-smntbmed P�^PenY far inspersion Purposes..,,
(we)agree to taus,indemnify and keep harmless the City of Cupertino against
.fes to liabilities.judgments,costs and expenses which may in any way accee against mid
z:U.Z City in consequence of the giaming of this permit. '
-'APPLIC'ANT UNDERSTANDS'AND WILL COMPLY WITH ALL NON-POINTISsuedb . Date
SOORCEREGULATIONS. . . . y. Date
u tlefined b the Cun n o.tMunia (Code Che ter 9.12 and the Healtn aM S. Re-roofs
Signature fpppi : .
_ HAZARDOUS MATERIALS DISCLOSURE6. Type of Roof.
W II the appl cunt br M build ng occupant store or handle hazardous S.f.t l -
Y D< Pp. P fnY
Code SM pit 733331,I t I. S it
Ores-.1• I,%gryo' , __All.roofs shall be inspected prior to any-roofing matenal.being installed _.._..__.
Will theapplicant or future building occupant use eq pment or devices whish If a roof is i'.stalled Without first obtammg an inspection; I'agree'to.remove
enat heriutlons air c t m no rx as refined by the Bay Arca A Quality Management
Dsmn all new materials for inspection. Applicant,understands-and will,comply with,
all non-point source 2egulations., .
t ,
I have mail the hprardous materialsman,.cmems under Chapter 6.95 of the
Calil'oinla Health&Safety Code,Sections 25505,3533 and 25534.1 understand that
if the building does not currently have is tenant,shot it is my.responsibility t.notify the s
ocqupantof Ne regniements which must be metpnor no ssiu.nce,of a Ccrtificam of
bpeacy Signature of Applicant.__, _ „ .-__. _ _ _ Date_-,_
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o nr o ..tarn Ra gent Date.. .. All roof coverings to be Class"B"or better
OFFICE .-
r ",tor