03010167 crry OF cuFER,rtNo e:
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS; HOT WATER INC PERMrr NO.
20710 RODRIGUES AV 03010167
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATI7
FU LIN 01/282003
IONS: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB mini
WOO LICENSED CONTRACTOR'S DECLARAB'ION .IOb Description
O U I hereby affirm mart)am licensed node pn vanam of chapter 9(enmmeoeiog p
s with Ser,ion 70aBof Divisors J of the Busines Profcuions Cad,and my license is
G y h11=11ee n rl y � REPLACE WATER HEATER. FRIMALEM
F„�z E.mertsc Ice Lin.
�c Dare cnm�tu{
qaQa',j' ARCHITECTS Dor. RTI N 2003 oyU lenders nJ my plans xhall he uwJ as public recnNs JUN 1 LO
:0 Licensed Professional
tkp— OWNER-BUILDER DECLARATION
5y u� 1 hereby affirm that 1 am exempt from the Contractors License Law for the BUILDING
ti—00 following reason.(Soction 7031.5.Business and Professions Cale:Any city or county
SE which requires a permit In ennseu¢,ahep improve,demolish,or repair any structure
in
prior to its issuance.also requires the applicant f or such permit to file a signed statement ��yy,,��
1p-�< that he is lice Bred pursuant in the Provisions ofine Contractors License Law(Chap¢r9 Sq.Ft. Floor Area $yya20tion
y�$ (commencing with Section 7IXNp of Division J of the Business and Professions Cede)it
r3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollars($50o). e Occupancy Type
I,as owner of the property,or my employees with wages as their mile compensation,
will do me work,and the swcmre is not intended or offered far side(Sec.7Baq,Business
and Professions Code:The Contractor's License law does not apply to an owner of 506 - GAS TE tore nspCC Ions
property who builds or improves thereon,and who doessuch work himselror through his
tin employees,provided that such improvements are not intended oroRered for sale.If, 507 — FINAL PLUMBING
however,use building or improvement is sold within one year of completion,the owner-
builder will have the bordcn of proving that he did not build or improve for purpose of
able.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
concoct the project(Sec.70H4,Business and Professions Code:)The Conductor's Li.
cense Law Jrcs not apply to an owner of progeny who builds or improves thereon,and
who contracts for such projects with a contracmr(f)licensed pursuant to the Contractor's
License Law.
1 am exempt under Sec. ,B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self insure for Worker's Compmr
sation,as provided for by Section 3701 of the labor Code,for the performance of the
work far which this permit is issued.
I have and will maintain Worker's Compensation Insurance,u required by Section
3710 of Ne La rCo forme oft, of the work for which this Permit is issued.
My Worker' pen J'nn c and Policy/n�llmb ', �t/p
Cartier: ` epalicy Nr/: �yaP'
` / CI:RTIFICAI'EOFEXEMPI'IONFROMWORKERS'
.�f, COMPENSATION INSURANCE
(Enissection need nm be completed if the permit is Intone hundred dollars D100)
or less.)
I cenify that in the perifim ance of the work for which this permit is humid.1 shall nm
employ any person in any manner so as to become suplect or the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICAT:If,after making this Certificate of Exemption,you should
become subject ret the Worker's Compensation provisions of the Labor Calc,you must
O ,Z forthwi in comply with such provisions or this permit shall be deemed revoked.
Z O CON.SIRI1CnONLENDING AGENCY
F+ rN-r-r Ihereby alYrm mat mere is a concoction lending agency for me performance of
X 7 the work for which this parr it is issued(Sec.LPD.Co.C.)
Q lenders Name
z lender's Addreas
U Q 1 cenify mat I have read this application and state that the shove information is
LL H correct.1 agree to comply with all city and county ordinances and slam laws relating to
DU building consendeion,and hereby auNorive representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino again
fq Iiabili lies,judgments,casts and expenses which may in any way acerae agai nn mid City
U Z in consequence of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILE.COMPLY WITH ALL N -PC
P NET Issued by: Date
SOUR GUI,ATIONS. f1 ti
Re-roofs
i a ApPli.mJContr.mr to,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant store or handle hvardous material
as defined by the Caperton Muniypal Code,Chapter 9.12,and the Health and Safely
"MILCod,Sadocx.95532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y �
lWill the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nit M1aruniZs air contaminants a.` alined by the Bay Area Air Quality Management all new materials for inspection.
Diu a7
Vcs
I Imve read me haemdnus materials requirements under Chapter 6.95 of the Cali for-
niaHealth&Sofety Code,Se,6,.25505,25533and2553d.lunder anJWtifthc 'Iding
Jots not cone y have a recant,mat it is my responsibility to notify the oc pant f me
requiremen h hmastMmet pnnnn issuance of a Cenificato el 'c at � n� Signature of Applicant Date
Owncw thorixcJ agent Dane V All roof coverings to be Class "B"Or better