01080058 OF
TINO
CI Nut DING DIIVIISSIIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21170 RAINBOW DR HOT WATER INC 01080058
OWNER'S NAME: APPLICATION SUB DATE
TSE FRED M AND PATRICIA G 2531 GRACELAND AVE 08/10/2001
PHONE: SANITARY NO. CONTROL NO.
(650) 298-8494
o m ARCHITEC rENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH
z S v LICENSED CONTRACTOR'S DECLARATION Job Description
O ce •o I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
F_ w withseaion7000)ofDlvi,inn)„fineBaeines,andProfesion,Code.andmylcense GE PROFILE PERFORMANCE SMARTWATER WATER H
a tse y is in full force and effect. INSTALLATION
c r..<u •License Class Lit.N +
3 LL y Dutra Cnmraclor I
ARCHITECP'S DECLARATION
Y 1 undemm�d my plans shall be used as public records 1
w E 0 2 U,,cwh d Professional
n w o u , OWNER-BUILDER DECLARATION
1 hereby affirm Iha 1 am vempt from he Centra lot's License Law for the
following mason.(Section 7031.5.Business and Professions Call.Any city or county
fFC 'which rcquiie. t to constract.all p J Lh.or o,pair anyst score
i3 r.
-prior to itsI moninas the pll' t for such pernat file a vie led statement .p --
Nprtp 1 s ip I-p11n pn ,t In c n t I 'Chapter t Sq.,Ft. FloorvArea,-, - Valuation
(en ¢t Ih bei 90001 of Divi u Sof the B4,9ne dl .futons Code) f_' 1
or that he is exempt(therefrom and the basis forth alleged exemption.Any violation
of Section 9011.5 by any applicant for a permit subjects the applicant o a civil penalty
sof ant..to man me hundred dunar,($5Ln). umber .'>�" '^ Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work;and the structure is not intended or offeredforsale(Sec.700,
Business and Profeaion,Code:The Contractor's License law does not apply to an 506 - GAS TES'IRequired Inspections,
owner of procn
py Who buildso,improve,thereon,and who dues such work himself
orr th nM1rougb his own employees.provided that such improvements arc not inlander or 5 0 7 — FINAL PLUMBING
�dRcrcJ for rule.If.M1oweveq the building � iovemem is sold within one - f -'- "-� � - -� "��- "'--"' '"' ""—"_._....
ot imp car ,.l .tN
oproveifar the owner bu Ic.),will have rhe Maden of proving that M1e dIA not buil)or
improve for purynm or sale). '
❑1, p pc YInmrofessi with Rccosehrontmcton
emn.l a the does
(Sec, 1.a owtho J e Profession.,Cod ITh C t ler s
+. laic Law Jme not apply man owner !p pent whoM IJ.„ ,,rop thereon, �fm� ��qT� ^ R �y
and-who commas fa such projects with. < t uchms)IicensW pursuant m the %j1,"_.pNs u'PQ'S' 1' ry m 41J
Contructur s License Law. J -
El in c,e.,t code,st- B&PC for,this reason
O.G th yyq Nr'k 3 '0 2002
- ' Date .. . R I1 SU VL
WORKERS COMPRNSATION DECLARATION <
I hereby affirm under penalty ofiserjury one oldie following declinations: - ,}y y 1 p� BUILDING
I III DING
0'1 have and will nui.hun o Cenificatn of Consent to self-insum for Worker's JUIL.DING �/ L IYV
Compensation. as provided it,, by Section 37W of the Labor Code. for the
perlo.c of he work for which this .if is rosier.
❑1 have and will maimoin Worker's Co nothouIon Insurance,a,Fequind!by Section
3700 of the Labor Cale.for the Performance of the work for which this permit is
issued,My Worker's Compensation In carrier and Policy number art:
Carrie,: ' Policy No.: ..
t'. 4 CERTIFICATION OF EXEMPTION FROM WORKERS' `
,COMPENSATION INSURANCE'. ” ' .. ___.. ._....__.. .__ .. .___.__ _
(Tb lkmninn need not be complacd if the permit is for one hundred dollar
(SIM)or less.)
1 cempl that in IIs performancenn the work for which thissubject
p tine altni.ker I
',hull not employ any person in any manner so as to bttanw subject w the Workers'
Compensation auanion Luws of Cnlil'ornin.Dare
cant
NOTICE TO APPLICANT:It.after making this Ccnificamof Enempiion,you should,
'bc' subjectu the WorkersConpcnsi p ons ofthe Lah Cuda. .a most
O
(an h Ih c mpiy withsuch provision,o thispermit shall be dee vd revoked
CONSTRUCTION LENDING AGENCY
1 hereby offirm that there is a construction lending agency for the performance '
of the work for which this penin is issued(Sec 3197,Co,.C)
Q 'Lender's Name ._ o _ .. .. .. ... _. _
LLender s Address
V 0 I eenify that 1 have mad this application and state that the above information is
fix. Fx correct.1 agree to comply with all city and county ordinances and state laws relating
Q t, nobMsove-mentioned nand hercinspectiby on puposentatives of this Illy to enter upon
r� the abo(We)agiomd prppcny for inspection p hantee /JttyJ�fJlf"p'/,y/I 5
ON (We)agree m,aw,and a peno,v keep h may in
the City of Cupeni ai against(sid ( �
(Al liabilities,lohfi m e egos and expofthi which may in ony way acct uc again,)said
U Z City I csmsT UNDERSTANDS
ilANDSnANof thispermit.
tS SOURCE
RE UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issuedby: Date
SOURCE REGULATIONS.' Y'
Signature of ApplicantlComn¢lur 'Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Wm me appfcnm a fano buildmg,nCOPtm aOrc or handle hatobiou,maed:d Type of Roof
as JefinN by the Cupertino Municipal Cale.Chapter 9.11,and the F—i and Safety
a>vy
'f Section 355321 a)2,
oyes "" 0 No All roofs shall.be inspected prior.to.any.roofing material.being_installed......__._. ...
.Win the applicant or future building occupant use equipment or deviets which If a roof is inst9lfed without first obtaining an inspection,'( agree to:remove
mit M1aruNtw,yr conmmimnns as defincA by the Bay Area An Quality Management
its un? all new materials for inspection..Applicant understands and will comply with .
ores 0 N all non-point source regulations.
1 have read the herallous mammals requirements under Chapter 6.95 of the
C.bul,iha mold,&Safety Code,Sections 25505,25533 and 25534.b undcrstaod Oat
if the boildingdoes'hot currently haves tenant.that it is my responsibility to notify nhc:
'occupant of the requirements which must be met prior to issuance of a Cenificme of
Occupancy. ,
, Signature of Applicant _ _ ," _ _ Date
Owner or call.gent . . - Dam All roof coverings to be Class "B" or better.
OFFICE _.