03010165 CITY OF CUPER'PINO
1 �h
BUILDING DIVISION PERMIT m,CONTRAGTOR INFORMATION
BUILDING ADDRESS: HOT WATER INC PERM IT NO.
21617 ROSARIO AV
OWNCIVS NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
JAMES HO 01/28/2003
ONE: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
1�'u00
LICENSED CONfRACaOR'S DECLARATION
F I hereby affirmm thatohm I am Iidh aF ir?Pmvisinm n!Chapter 9(commencing Job Description
!K3 with Scclinn ivi.cinn3nf NC BusinBR and Professions C�dc,and myliccnsc is
L5N�
✓S( 2� REPLACE WATER HEATER
ZC-Z DLic,pP_H� DClmsDen fI'ILCTSIIARATION�omull Mau public records 2��3
LLO LicensedPmfessmod AUG 2 1
OWNER-BUILDER DECLARATION
s <2 1 herehy affirm that I am exempt form she Convanoia License law for the
m¢p0 following amano(Section 71p1.5.Business and Professions Cae:Any city or county BUILDING
$ which requiter a permit In ennahtxl,alcor,improve,demolish.or repair any sumeure
Prof In its iamanw,x1,111 rapcires the applicant on such pemsil III Elea aigncd slntcmc l
That he is licensedpunvsmnnnlheprovisioinsoftheContractorsLicenseLaw(Chapter9 Sq. Ft. Floor Area $Y"tion
(commencing wllh Section aft)of Division 3 ofshe Buslnessand Professions C4le)or
y that he is exempt melefrum and she basis for she alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects Ne applicant to a civil Penalty of
nos more than five handled dollars($5001). e Occupancy Type
0 1,as owner of the property,or my employees with wages as their sole compenulion,
will do lire work,and the auuctum is not intended or offered for sale(Sec.70P,L Business
and Professions Code:The Contracmrs License law docs not apply to an owner of 506 - GAS TE wre nspec Ions
progeny who builds orimpmva thereon,and wlsodassuch work himself or through his
own employees,provided that such improwmenl as not intended proffered for sale.If. 507 — FINAL PLUMBING
however,Ne building or improvement is sold within one year of completion,me owner-
builder will have rise burden of proving that he did not build or improve for purpose of
Ile.).
1,as miner of the propcny,am exclusively contracting with licensed contractors to
consume the project(See.Il44,Business and Professions Code:)The Comments Li
cense Law does not apply to on owner of property who builds or improves menton,and
who contracts fnr such projects with a contraclor(s)licensed pursuant to she Contractor'
License Low.
❑I am exempt under See. B&P C fnnhis reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ceni Beate Consent of Conseno self-insure for Warker'sCompen-
ast on,az provided far by Section 37M of the labor Code.Tot me peRnrmana of me
work permit is which this peris issued.
❑I have and will maintain Worker's Compensation Insurance.u required by Sectio
3700 of Ne Lahorcrde.for the performance of uhf`u t fnr which this permil i issued.
My Worker's rm sasio surencec 'coed it
number
Cam r Polity Np.:
CERTIPI TE FE%EMPnONM WOR ERS'
COMPENSATION INSURANCE
(This seeiun need not be completed if IM permil is intone hundred dollars(S 100)
or less.)
1 I anify shat in the performanm of she woyk for which this omit is issued,I shall net
employ any person in any manner,so as In become subject o the WorkersCompensation
Laws(if California.Date
Applicant
NOTICE.TO APPLICANT:IL after making this Cenilicate of Exemption.you should
become subject to me Worker's Compensation provisions of the lalasr Code,you..It
0 Z, forthwith comply with such provisions or this permit shall be deemed awaked.
z O CON S'rRUCIION LENDING AGENCY
[-+ C7 I hereby affirm that there is a construction lending agency Iorthe performance,of
CYi me work for which this permi t is issued(Sec.30U.Civ,C.)
LIJO Under's Name
Z I.cmdcr's Address
U 0 1 certify that 1 have read this application and some that the above inlinmminn is
Wk P comer.I agree to comply with all city and county ordinances and state laws relating to
DU building conslonion,and hereby authorial mpaunotiws of box city to enter upon the
r If] above-meminned properly for inspection purposes.
(we,)agree to cast,indemnify and keep harmless the City of Cupertino gan.Fv against
U N incoitiequeroc ofthe cnstsan ofthissevolwhich they in any way accrve agaimis'ICI
ty
LICAcncc of the granting of this pc WILL
U^' A�LIC T UNDERSTANDS AND WILL COMPLY WITfI LL ON� DINT Issued by: Date
RC R U ATIONS. _ {f h'S
�/ V Jl Re-roofs
Signature of ApplicanUComrarou Dal
HAZARDOUS MATERIALS DISCLOSURE Type Or ROOF
Will me applicant or future building occupant stare nr handle harardnus material
as dFFned by the CF,ai no Municipal Code.Chapter 9.12,and the Health and Safety
coWe.Sctann zss3za)7 All roofs shall be inspected prior to any roofing material being installed.
4Yea �Nr
Will the applicunl nr tutu c huilding occupant use equipment ser devices which
If a roof is installed without first obtaining an inspection, I agree to remove
Poor holudous air conominanu o delhaed by the Bay Arca Air Quality Management all new materials for inspection.
Do..
❑Ycs
1 hast read me harardnus material mpJremenu under sk,For dens Ifs,Culmung
onesWturemlyow Ionamin,25915,lay mrd 25534. ask,Ford malif We huilding
Jas not cnrremly how a coram,mat it is DIY rcap+raihilil m aify tM occupant of me
require is ichmustMrt
me,P000issuanceofaC ¢n d xup c' Signature of Applicant Date
Onr amhnrircU agcm n 2
0Date All roof coverings to be Class "B"or better