02100136 CITY OF CUPERTINO '^"'
BUILDING DIVISION PERMIT vC-0NTRACT0R4NF0RMATI0N-
BUIL 1 QkFS37 STELLING RD. HOT WATER INC PERMFrNI02100136
GWr NdTiIEiL RUIZ 2531 GRACELAND AVE APPL'C-T9YT`V5rY2002
IIONE: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHI'I ECUENGINITER: BUILDING PERMIT INFO
RLDG LLECf PLUMB MECH
woz LICENSED CONTRACTOR'S DECLARATIONInh p
itedC 1 hereby affirm that I am licenm:d under provisions of Chapter v(commencing REPLACE WATER -HERT ;`Prion
G-6 wilIScctio0700),oDivido.3ofheR.Arlesaandpfofusiin.,CoJe.andon,free.ia
in loin Ba ce and effect.
Z�4 Z License Class [.it.a
—p DaleContractor
ve ARCHITECTS DECLARATION
ya 1 understand my plana shall he used as p.hire retards
4�tV
tu;u.n Licensed Professional
=fig OWNER-BUILDER DE CLARATION
�'u�<4 1 hereby atlirm that 1 am exempt from the Contractors Licensor Law for the
$634
to a 00 following reason.(Section 7031.5,Business and Profcuinns Cook:Any city or county
's�Q which requires a permit or construct.aper,improve.Jent9lkh,or repair any structure
prior m its osmucc,also requires the applicant for such Permit o file a signed Statement
that he is licensed pursuant to the Provisions of the email License Law(Chaplin 9 3S�63.0IDob@AIQk Valuation
ac a (commencing with Section 7000)of Division 3 of the Business and Professions Code)nr
y Nat he is exempt therefrom and the tamia for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemitsubjece,the applicant to a civil penalty of PN-N eeuparcy Type
not mom than roe hundred dollars P1500). 506 — GAS TEST
❑L u owner f the pmpeny,or my employees with wages as their sale compensation,
will do the work.and that someone is not intended or offered for sale(SCC.7044,Business
and Professions Code:The Contractor's License law does not apply to an owner of equlle OSPCCt10uS
pmpeny who builds or improves thereon,and who Jens such work himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If,
however,the building or improvement is sale within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.). n
as owner of Ne property.am exclaaively contracting with licensed contractors to A L E
emagr a the Mount(,Sec.70,t4,Business and Pfofegoons Code:)no Conuaemr's Li-
comic law dues not apply to an owner of proPeny who builds or improves themon,and
who commit.for such pmjcc.with a uonuaaor(s)barmaid Immortal to NC Cnnuacmr's DOT
n as �oos
Licenor Us. 11.. I ( (, C
❑ l am exempt under See. .B A,P C for this reagin
Owner le BUILDING
ORKCR'S COMPENSAT ON DP,CLAR ION
Sk 1 hereby affirm under Penalty of perjury one of the following declarations:
0 I have and will maintain a Cer ificae of Consent)self-maure for Worker's Compen-
action.as provided for by Section 3701 of the labor Code.for the peefmmaece of the
work for which mus permit is issued.
I have and will maintain Worker's Compensalion Imurance,res required by Section
3701 of the Labor Code,for the Ierforntancc of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Canicr: Policy No.:
CERTIFICATE OF EK EMPFION FROM WORKERS'
COM PENSAI'[ON I NSU RANCE
Mis section need not be completed if the Permit is for one hundred dollars(S 100
,it less.)
I certify that in the recommence of the work for which this Permit is iamal.I shall not
employ any Pers .any manner so as to become subject the Workeri Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:B,ancr making this Certificate of Exemption,you should
hecome subject in the Worker's Compensation provisions of me IaMn Cale,you mag
OO forthwith comply with such rmvisiomor this rermilshall M dccmcd mvnkcd.
r N CONSTRUCTION LENDING
)7,Ci, .)
[--i I hereby alum that mere is a connotation lending agency lot perlorma.cc of
a 7 the work for Which this pCrmil Is issued(See.3119),CIV.CJ
0. QLcndc,�a Name
G LcnJcia AJdmss
V 0 1 certify Nal I haw read this applieation and sum Ihat the above information is
V. H cancer.I agree to comply wit all city and county ordinances and slate laws relating In
O V building conduction,.ganJ hcrchy anthonrepresentatives of this cirymenmrury,n the (\ntyr(/I //�///�/S
a bovelmemidgmento,cos an inspection whichpurposes. /"ted
(We)agree to save,indemnify and keep harmless the City of Corcoran against
E-' h in
Of th granting ext,canof this pe which may in any way aeerve against said City
J inam.m ANT of UNDERSTANDS
althispermit.
^� APPLICANT UNDERSTANDS ANU LL COMPLY WITfI ALL NON-POINT Issued by: Date
SOURC EGULATIONS. \ /
�/MG�,61//1�(—� J( � Re-roofs
�f ApplicanUCenuactor S Data
...�� HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building necupant nnre or handle hmarJous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the IRath and Safety
Cade.Section 25S32D)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes iNJsa
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
air haeardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District,
Yes
I have mail the hasardous nnlaerials requirements under Chapter 6.95 of the Califon
ma Iieulth A Safety Cole.Sections 25515,25533 and 25534.1 undpaund that if race building
does not currently haw a meant.Nal itis my easlmmibility m mail y the occupaal of the
requirements which mug be seal IF m' eat.Cent neatq of Wo Signature of Applicant Dale
DWnao aathorioni Loun, Data All roof coverings to be Class "B" or better