01090089Z
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CITY OF CUPERTINO
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CONTRACTOR INFORMATION:
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Bou.gtNG'DivtstoN PERMIT.
BUILDINGADDRESS:
PERMITNO.
22395 ST ANDREWS AV
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'HOT,WATER,.INC
0109Q089
OWNER SNAME:
;I
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APPLICATION suBDATE
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(PHONE.
_.._2531..GRACELAN '
D._AVE _.:..._. _._ -..09/20,/2.0.01
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SANITARY NO. CONTROL NO.
(650)298-8494
ARCIIITECr GINEER:'
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
hereby amrmlhalamoftheBusinunder
sandsiamof sions ode.andmmen6rg
with senior 3 o the Business end l'rcfessions Code. and my liana
REPLACE WATER HEATER . -
is in full face and effat.
and effect.
LiccnsIClore as
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Data Contractor
ARCHITECTS DECLARATION
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ed s
1 undersand my plans shall be anti as puhlic recnda
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Licensed Professinwl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following (Section7031a Business dPmf s In Code Any city or county
which reg m permit construct, h r.' prove d moliah, or apmr any structure
-anon tarn ee Isorequ the pale If aochpemnuofileangaadsraamem
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thlat beacepar .I'c sed ansa n7 ) 1 n fth Cot wh L (Chapter 9
to atgaeasand Prar a rocme>
Irthaa<gwnhSmionari
y �. [cQ��a�a ! ! `
('(p,e4 3.5 0, 0 °.53. L11Ti.6_t�.',i
Valuation
baiisor to
and
or that io is exempt therefrom and the .pals for the allege) ncmpood. Any violation
�f.
of Station 703La by any aPPlicvnt for o pcnnit sublets Ute apPlicenuo v civil penalty'
of not mom than five hundreddollars(s500).
502APPNV L PLUMBIN
ENERGYOccupancyType _
❑I, as owner of the propeny,u my employees with wages as their sale compensation.
I.'
507 - FINAL! PIRftW1llQspections" •
will do the work. ead the swnum is not inanded or offered far sale (Sec. 7044,
'Business and Professions Coda: The Con rector'i License Law does not apply m an
_owou of propemy,Wha builds or improves thereon, and who does such work Mmulf,
,Lir through his own emtoees..ovided that such im- a are not intended or --
:bfferad or sale, lL howevca the Wilding or improvementisesold within one year of
completion, the owner -builder will have the burden of proving that he did not Wild or
improve far p name of'.1'.).
+
01, as owner of the pmpeny, can exclusively comrdcrng with licensed convacmrs to
construct the Project (sec. 7D14.'Busim a and Proreasimis Code:) The Contractor's
License taw does not apply to an owner or propeny who Wilds or improves thereon,
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end who contracts for such projects with n omracmr(s) licensed pursuant to the
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Comranors License Law.
O l am exempt under Sa. .B&P C fm this. nation
j"t .,t
Ow"mer' Dam
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WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty or perjury one of the following decimations:
have end will maintain a Certificate of Consent to self-irtua for Workers
Cbmpersaicr, as.provided for by Section 37W of the Labor Cache. for the
performance of the Work for Which thio pertnil is Tuned.
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❑ I huve and will maintain Worker's Compensation Insurance, as hatined by Section
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37M of the ISM, Code, far the parforaarana of the work for which this Permit is
issued My Workds Ca pe itYIxumnce came and Policy number are' n,
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'Poli
Cather
ss
s'• a„ 14,,
Is
CERTIFICATION OF EXEMPf10N FROM WORKERS i
t ,<-- A ., L�'e
COMPENSATION INSURANCE.
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frits section veW Iwt he compicad f the permit Ls for one hundred dollars
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t t -' .' • Is`
S10 Or or less,)
; enc a of the work for which this ro�it at issued, I
" I amity Thai the
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Sec
shall not employpct rson In an so m become subject to that Workesi
in tin
Y.Pe Ymavncr.
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Compensation Lews of @lifomie. Date •--- .•.h...
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. Applicant.... e• ... .. .. ..
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NOTICE TO APPLICANT: If, afar ranking this Cenificaa i f Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cade, you must
fom.with comply with ahch provisions or this peretit shall be deemM revoked.
n' 'CONSTRUCf10N LENDING AGENCY ''
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1 hereby eRtm that them is a construction lending egenry foi the a from
of the work' for which this permit is i ... ad'(sac. 31Yf7, Civ, C.)
Lender's Name
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Lardar'aAddress
I amity That I have read this application send .10 that the above infomatton is
-meet. I agree a romply with all city and county ordinances and state laws relating
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N V/✓,�. ��t
to Wilding conswction,and hereby authoaizdaprcuntatives of Nis city to enter upon
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the above-m_cntioned pmpcny for inspection puryous.
s (We)agrcctoreeve. indemnify end keep h.,Icss the City of Cupenom against
liabilities, judgments, cons and expenses which may in any way mems, against said
City in consequence of the Scanting of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT'
Issued. Date
Y•
SOURCE REGULATIONS.
Signature ofApplicant/Conwcmr Data
Re-TOOfs
HAZARDOUS MATERIALS DISCLOSURE
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Well the a ort t ni ipilding occupant Hort a handl h l
Type Of -ROOF •.. , ... - •- - .. ..
eadwn Safer
n defined by the32pd_ Municipal Cade. Chapter 9 @. std the Halth and Safety
s Cupertino
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Cade Section 235121x) r'!s i.il :'
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�a...h."•..` ri, f: 1,.!•:(i]ts k.
Oras ❑Nn'.'.. .,.
.. All.roofs shall be. inspected.prior.to any,.roofing.mateiial.being installed.
•,.Will tht.pplianlor fouraWilding occupant use equipment or devices which
If a roof is installed without first obtaining an inspection; I agree.to;remove
emit herammus air contaminants n defined by the Bay Arca Air (Nalky Management
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all, new,materials;for inspection. Applicant understands and will comply with
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- all non -point source regulations. ,.
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.lf.mi.Hc'readphe)liy Cade,s 'et tithe
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andstand,1undo that
hot Health& ections2ayvircm33aunder4. I un
iode.Sectionsant.tht
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of it a notify the
ifthe W ilding doer notnapscurrently hart a motif
if that II La my nuance
must W Of &
Pont of the requireera which must W met prior to issuance of a Cenificaa of
a<awP<y.
Signature of Applicant Date
All roof coverings to be Class "B" or.better
Owner or authorized agent Date
• .- i OFFICE •,
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