02050128 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RYIrPTWRfftDGEWAY DR WATER HEATERS ONLY PERMIT NO. 02050128
9Uftt2"EGRANT H AND ELIZABETH H 970 E . MAIN ST, SUITE 20 5G{'�°I D�2
PHONE: (415) 566-2209 SANITARY NO. CONTROL NO.
rc Z ARCHITECTMNGINEER: BUILDING PERMIT INFO
as pOp BLDG ELECT PLUMB MECH
L-D
o K LICENSED CONTRACTOR'S DECLARATION
� �o Ihcrcby uffrdomilom licensed under provisions of ChapterYlcammencing REPLACE WATER HL' 'IFrip[IOn
.�I� with Scdion]000)of Oivision3oflhe Businessand Profession Cale.end mylianse (40 GALLON GAS)
in full force en t.
0 a.V Littnse s c Q Lic.M 7 _
Date al Com wor
1 O G, ANCNITECI"S DECLARAT N
Y aj 1 undcrxiond my plans shall be uud es public records
i w o O Licensed Professional
'r n 2 OWNER-BUILDER DECLARATION
i hereby affirm that 1 am exempt from the Contractor's License law for She
t?z< following reason(Swim 703 1.5,Business and Professions Code:Any city or county
I❑C which requires a Permit t0 construct.alter Improve,demolish,or Rpalr My structure, $700
prior to its issuance,also requires the applicant for such permit to file a signed statement - -------
for he
----Natheis licensed purruai to,be provisions or the Contranofs License Lot,(Chapter 9 s., ., •� Are - - Valuation
70010) Sq FLT Floor Ar
,. or that o ing s exam t theionom-and the basis or t the Business and Professions Code) ♦, , I .�„3 1,e �'Y t l\
or that io is exempt therefrom End the basis for the subject,
thalleged exemption.Any violation '3 42 41 O 11'. O O'
of Section 7031.5 v aoundomicoll rs a permit subjttts the applicant to a civil penalty-
of hatmnremanfivehumreddonars(Ss00). APN Number it" Occupancy Type
°I.as owner of the property.or my employees avian wages smei,sale coronations., 502 - FINAL PLUMBIN ENERGY
will do the work,and the sweture is not intended or offered for sale(Sec.7044,
Business and Professions Code:The Contriscmr's License Law does not apply to an ! specDOns' '
owner of property Who builds or improves thereon,and who does such work himself 507 - FINAL P
or throw It his own employees.provided that such improvements are not intended or _
offered for sole.If,however,the building or improvement is sold within one year of
completion,the owner budder will have the burden of proving that he did not Wild or
improve for purpose of sale.). (7 i
01 it. what of use MopnY am udusively contracting with li<enscd contractgqlato+ jhf. • - - I -- tconstruct the protea t$tt ]044.Business and Protestor, Code)The Contredto L
L se Law does not apply to an owner f property who builds r'mp wu thele -
:. und,wh.contracts,for such projects with a contracui licenced P moon t
_
Contractor amaro ense usualaw. - / I ^r'r
111 am exempt usual Sec.' B&PCfor this U// _ _
Owner . Dae '
- -' WORKER'S COMPENSATION DECLARATION
1 hereby offrm under penalty of perjury one stores following declarations:
❑ 1 have olid will minimum a Certificate of Consent m self-insure for Worker's
0, Compensation• m provided for by Section 3700 of the Labor Code, for She
performance of the work for which this permit is issued.
�4�
will maintain,Wnrker's Compensation lnmrance,m required by 5&tion
]00 dLoboI Code f rthe perfo antePi s ed Compensa0on InsurancecartCam iPl y No
., ' f sY 1 ! .J,i1, .., .i, ..
CERTIFICATION OF EXEMPTION FROM WORKERS - , - .COMPENSATION INSURANCE ..
(This senior need at he completed if the permit is far one hundred dollen
($100)or less.)
'
Imrofy that in Sh peif mance of the work for which ths Penn is issued;1 •' - t„; - .i -
'shell not employ any person to any manner so as to become subject to the Workers
Compensation Laws of California.Date
Applicant
NOTICE TO APPLICANT..'lf;after making this Ccrtificam of Exemption,you should •
become subject to the Workers Compensation provisions of the Labor Code,you must
Q forthwith comply whir such previsions s or this permit shall be demand
med revo_ked.
CONSTRUCTION LENDING AGENCY
dGI hereby affirm that Shore is a c nsuuct n lending agency for the Timm mance
{>J of She..sly for which int Penn t s issued(Sec 301 Civ C.) -
Q Lenders Name -
o.z Lender's Address''
V0�+t Icenify that l have read this application end also,that the above information is
lit ri correct.1 agree to comply with all city and county ordinances and state laws relating
V to biildia2 cimaAction,and hereby amhorizerepresentutives ofthia city to enter upon
W She above-mentioned property for inspection purposes.
6 (We)agree io save,indemnify end keep harmless the City of Cupertino against
(A liabilities,judgments.costs and arimeas which.may in any way accrue against said I
V City inconsequence of She gmming of this sit.
AlpI]('ANT UNDERSTAN A LL OMPLY WIT .LL NON-POI r' Issued by: r Date
SOURCE REGULATION. y Y
Signature'm Applicam/Con actorP/ ate Re-roofs
HAZAFUDOUS TERIAL9 DISCLOSURE
Will the applicant or future buildingemulatorru,m hostile hazaNaus mancrod Type of Roof,
is defncd by Ne Cupertino Mon apt Code Chapter 9,12,and Ne Health and Safety
Code Section 25532()+ 'I
°Ye = ' ' All roofs.shall be inspected..pnor_o any.roofing material.being installed.
Will the applicant or future building occuPam use equipmem ar device,which If a roof is installed without first obtaining an inspection',-I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District❑Ye. ° all new materials for inspection.•Applicant understands and will comply with
all non-point source regulations....
S.� 1 have rcod'the hazeidous..,costs requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505.25533 and 25534.I understand that
if the building docs not currently have a tenant.that it is my responsibil ity to notify the
hccupnt of the require ,which must be t prior to Issuance of a C nifmam of •�
Occupancy.
S j� Signature of Applicant Date
Owner or authorized eg - /DoT All roof coverings to be Class "B”or better
µ ....0 _ ... . ..... ._ _ .. - OFFICE