01100089 OF
CITY
I BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21598 ROSARIO AV WATER HEATERS ONL`L 01100089
OWNER'S NAME: APPLICATION SUB DATE
CONNELLY THOMAS J AND DOROTH 970 E. MAIN ST, SUITE 20D10/15/2001
PHONE: SANITARY NO. CONTROL NO.
(415) 566-2209
O u0 o ARCHITECiENGINEER: BUILDING PERMIT INFO
w C BLDG ELECP PLUMB MECH
H<i L-1
LICENSED CONTRACTOR'S DECLARATION
5„? Job Description
a—O 1 hereby amfm that I n 3licensed undo provisions of Chaprer 9(commencing P
�C5 is in full force an effect. on3ofthe Business and Professions CsNe,end myli<enu REPLACE WATER HEATER
f m y is in full force and erten.
m os 6 Lirenu Class Lir,e
3LL U Date Counsel.,
ARCHI I LCI*S DECLARATION
In.
O 1 undcntaod my plans shall he mud as public records
i
st,
!z p O Licensed Professional
' o 0� OWNER-BUILDER DECLARATION
1 hereby affirm Nm 1 ain exempt from the Contracum's License Law for the
s_Z< following mason.(Section 7031.5.Business and Profession Code:Any city or county $700
A O which q Penton t construct, r
It ,improve w
demolish,or repair any s
cture -_ _
n37 Ill.h ss adpsabssorego thepir pplieaof thewchpecminobense La (Ch.,,.
_ __...._Valu
that he .I' . it p mot ie term pro i ons a the,ha Business
License Lew(Chapin) pp N R0,9 Ib p i
(comm a is a with Section]0001 ofhe is is l ofihe tlunness and Professions Code) L(�'ss�y �3,'j',p' (J�,L U r,',(TGa S}I ry�g(�i"v Valuation
of that io is exempt therefrom and the bans for the alleged ecaminion.to Any violation V !
of Senior]031:5 by any applicant for a Permit subjects the applicant to a civil pewlry
of of more than five hundred dollars($500), 502” N-P-T `h PLUMBIN !ENERG YOccupancy Type
°1,as owner of the progeny,of in,employees with wages as shim sale cmnpensation.
will do the work.and the atrvctum is not intended or offered for sale(Sec.](114,
Basin<sa and Pmfesslons Cade:The Contractor's License law docs not apply to an 507 - FINAL 209044 [tlspeetions . . .
mer of property Who builds or improves thereon,and who does such work himself
or through his own employers.Provided that such improvementsare not anot intended or
offered for sale.If,however,the Wilding or improvement is sold within one year of
iompletion,the owner-Wilder will have the Widen of proving that he did not build or F 1 LED i
mprove for purpnu of xele.L
°I•as owner of the progeny,merBusinesslacontractingwith urc:)The Comeronto
roes eL w project(ser.]B L Business and property
who ills or The Genthemon, JAN ' 5 20021
License Low does not apply io en owner of progeny who builds or improves th<uon.
and who convacu for such pmjmx with a commercials)licensed pursuant to.the
Contractor's License Law. p
°I am exempt under St B&P C for this reason OUILD'ING {t,
Owner Date'.
WORKER'S COMPENSATION DECLARATION
I hereby alarm under,Ta rally of perjury,one of the fallowing dalamtions:
D I have and will maintain a Certificate of Conant to self-insure for Workers
Compensation, as provided for by Section 3700 of the Labor Cade, for d¢
'I"formos ce of the sm for which this pemtit is issued.
°1 have and will maintain Worker's Cumpenseiioranationce,as required by Section
3700 of the Labor Cade,her the performance of the work for which this permit is
issued.My Worker's Compensation Insurance envier and Polity number ort;
... .. —_. ._. ... . . -. _ ...,._. __ ... .........
Came ! •. i :1 s Polity No.: •s [t l... s a ,y{s. s- k s
!,I I CERTIFICATION OF E%EMPTION FROM WORKERS¢'
COMPENSATION INSURANCE .
(This action need iwt be completed if the permit is for one hundred dollar '' '
($100)or It
shall _. ..... .. •. - _. .
I cempIcyanin the performance man the work for o eh this ct to t e issued;l —
not employ any person in any manner w az to become subject w the Workers' "-'
pmpenmtian Lawn.of Colifomie.Dem
Applicant. -
NOTICE TOAPPLICANT:IL otter making this Cerdfcat<of Exemption,you should •I
Z becomith comply
t y the such pr Comps or this panelons of a doemor revok you muse
Q Q forthwith comply with such provisions or this permit dial)be deemed revoked.
F y I' +CONSTRUCTION LENDING AGENCY - t s
1 hereby affirm that them is a canswerion lending agency for the peffwmntt I
of the work for which this permit is Lowed(Sec.3097,Civ.C.) s
Lender's Name
Z tender's Address .
V Q 1 c<nify that 1 have mad anis application and w
alae t the above information is
'law ['ter 'form.I agree to romply,with all city and county ordinances and state laws relming J
to Wilding construction,and hereby authorize representatives of this city to enter upon'
ythe above-mentioned pm,my for inspection purposes.
(We)agree w save,indemnify and keep harmless the City of Cupertino against
Ln liabilitim judgments,costs and expenses which may in any way accrue against said
U.Z City in consequence of the Framing of this permit.' i
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.'.' Y
Sigmlme efAppbeaad7immucior DaeRe-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the aD lica t f mrc building occripam m or handle hLerdmx not I .TYpe of Roofas defined by the Cupemno Municipal Cod Chapter 9.12.and the Health ad Salcey _ [- s .vx .•v s _ sx
Care,s t z5y32(m All roofs aha 1
DyON. ' i? i Il be.inspected prior to any,roofing material being installed.
- Will the aMlicar,o:future buil dingoccupant use equipment ordevices which' If a roof is installed without first obtaining an inspection;,(agree to remove
emit hassrdo rs air ontaminants as def red by the Bay'Ar<a Air Quality Management'
Diaries - all new materials for inspection. Applicant understands and will comply with
Dyes, °"° all non-point source regulations. 1, ,
1 have read the haaardmo materials onriurttents under Chapter 6.95 of the
Colifomie Health&S.afdy Cwle.Sections 25505,25513 and 25534.1 undcrsmnd that
if the Wilding does not currently have a record.that it is my responsi6iliry to notify Ne
occupant of the requirements which must be met prior to issuance of a Certificate of
o"apanry:' Signature of Applicant Date
Owner or authorized agent. " Dae All roof coverings to be Class "B"or better '
. .• _ OFFICE ..