01040088 CITY OF CUPERTINO
BUILDING.DIVISION PERMIT CONTRACTOR INFORMATION:
ROMANO ADDRESS: PERMIT No.
J
OWNER'S NAME: APPLICATION SUB DATH.
HONE: SANITARY NO. CON"I'ROE.NO,
GWp
BUILDING PERMH INTO ARCHITECT/IiNGiNf;ER: BLDG I71-1iClPLUM11 MICA
auw I-1 1_I CI l_I
FSm
p N= I.ICCNSI:DCONIRACIOR'S DECLARATION Job Description
- I hereby.Rion that 1 am licensed under provisions of Chapter 9(mmmmming
0=�0 with Svv,mn7(g)11)n(DivisirnJame Buainca and PmfessinnsCWc,and mylittnxe
Ir i s In full farce and elect.
M., License Class Lie.. REPLACE 40 GALLON GAS WATER HEATER.
° 3 i N Dare C.nnrvemr
t- as ANCHITFC1"S DEC LAZA ION
Y I u.demm.d my n s
plahall Ix: W mas public records
co�co t�h
E.,O�O Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby aliirm that 1 am exempt front the Contractor's License law for the
C? following reason.(Section 7131.5.Business and Professions Code:Any cityor county
F O which ne,doe,apc in...to construct, It p civrinultith,or retni, y-I tore
co Pros t, be applicantl hoe nit Fleaa dma tem
a. Nallt edluwh tt t n It 'c t itt',Li,ense Law(Chapter 9 Sq. Ft. Floor Area Valuation
(cot h ng with Section 7000)ot Div' m3ortle0an ul Pink,..'ors Code)
sit
m Ism he,,e,nmpl tbererrom:hid oto noxi,Ehr Inn alleged exctnpton.Any viomtom
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty
nrnotmme ban livehunemddollars(SS00). APN Number OccupancyTY-pe
01.as owner to the prnpcn,ar my employem watt wages as their sale compensation.
will do the work,and the structure is not intended or offered tor sale(Sea 7044,
Imslnesa and Prul'us,lons Crile:The Contractor,License Law due,not apply m an "• egUlred Inspections
� h'of property Who nuilev or intpmvc,0scon, ,sae who dome inch work himxell;,rmrongh his own etoploye...provided thin such Impoocoarnn,aha ton intmtded it 502 — FINAL PLUMBING ENERGY
attend for sada If,howm'er,the building or Impmvemul i,sold within one year at
inmpletion.the hm'ncr-builder will have the burden of proving tom he did not build or 506 — GAS TEST
mprove for pam„r of ale.).
Ol,as owner of the pri am exclusively contracting with licensed cumracmrsu+ 507 — FINAL PLUMBING
sma,mic,tit lr i fIlc.h r business Iprotest...Code:)ThC t , he
License L J I pply I of property 'h build' p thereon.
Crn n I r l l l "f' its h it [sl re l - I + rte
ot I
❑1 um ue opt h de,-Sots .If&PC f or this recto CC��
Owner ENS T�
WORKERunder Penalty
COMnatty fNSAITONDECIAollowi]ON
I hereby vBinn under Peohy of perjury one of the fallowing declarations:
0 1 havered will h irinin a Crailwan, rel Consent m wlGinsure tin Worker's
Congm. tiom, a, provldcd It, ny Suniun )7911 at the I:oho, Code, fir the
palmmuncc oI h,work for which tri,pon.h is issued.
01 have and will maintain Worker's Cmnpcnsution insurance,m required by Section
3700 of the labs Cade,for the Peru onnatce of the work for which this permit is
.sued.My Words Comicnsition tramper,carrier and Policy number nm:
Carrier: Policy No.:
❑iRl'IFICAIION DI+EXBMPI'[ON FROM WORK17RS'
COMPENSATION INSURANCE
(Thiaaetion.coil not br complmd if the pone,is for one hundred dollars
D10(b m lea.)
1 cerify that in the performance of the work for which this Permit is issued.I
shall not employ any Person in any roamer so as to became subject to the Worker'
Compensation laws of California.Date
Applicant
NOTICE TO APPIACAN'T:If afar mekiug this Certificate of femnptin 1,you should
Este anm sahj"I m the Woo Hers Con tpc+aninn ro"io'no of the L.nhor Code,You must
Ofnehwith comply with such provisions laid,Peonn shall be dcm¢d revoked.
Ln CONSTRUCTION IA NDING AGENCY
> 1 hemby alBnm that there is a conanmtion lending agency Int the performance
of the work for which this permit is issued(Sec.30t Civ.C.)
L Q Landers Name
Z) z Lender's Address
U 1 cenil'y hhnt I hale rend this uppl lcnhlnn and sate tom the uhovv inforn+aton is
4. [`. mmvO.I agree to rm.id,with all city and coudiname,and smic Inas relating
V to holding construction,and hereby uuthoriccrcpresemmiens of Ili,city to cover upon
r R7 the abeve-mentioned pmpcny for impaction pyoses.
E" G. (W'e)a8reeu,save.indemnify and keep hornless the Cityur Cupertino against
h liabilities,judgments,costs and expenses ohich may in any way accrue against said
V City in cumesp once of the granting of this permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DUIE
SOURCE RrouixrIONS. y'
Signature at Appbcam/Cmnmctor Due Re-roofs
HAZARDOUS MAI'IiR1ALS DISCLOSURE
Will the appheamt or!care sandals aae.pant cure or nasals hu awun,material Type of Roof
as defined by me Capitol..Municipal Code,Chapter 9.12.and the Health and Safety
Care.Section 25532(a)'!
O Ycx 0 N All roofs shall be inspected prior to any roofing material being installed.
Wit the appummt or future haildingotta,sna.,a cquipnu,n h+r drvica which If it roof is installed without first obtaining an inspection, I agree to remove
haiI haianloo,out rnhn.uninon1,use defined by the pay Arco Nr Qundihy Manugancnt
metrial' all new materials for inspection. Applicant understands and will comply with
C3 Ye', 0 N all non-point source regulations.
I have read the hamrduus materials requirements under Chapter 695 of the
k California Hexlth&Safety CWC Sections25505,25533 and 25534.1 understand that
if the bhilding does not currently hero a term,that it is my ms,onsibilihy to notify the
occupant of the requiroenu wm
hich must be el prior it)issuance of a Certificate of
Om
Occupancy
Signature of Applicant Date
Owner is,authod,ad.gmm IAhte All roof coverings to be Class "B" or better
OFFICE