03020016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,'
BU ILDING ADDRESS: HOT WATER INC PERMIT NO.
10355 TONITA WY
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUR DATE
JIMIE WANG 02/06/2003
]ON[: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCDDECOENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MP.CD
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�upp LICGNSEO CONTRACTOR'S DECLARATION Job Description
�ulr 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p �'��iE®
p� with Satin.7(XXOof DivisinnJnl'tha Business any�Pr�fessions Codo, myense is
m"n,uca es, ir s,3 /(o REPLACE WATER HEATER
�'q= i.menae cls us,.a
F= Dam Gentraeto` SEP 112003
� y� nderstanal my PlanRshall hr uxJDEC hAR�mJs _
pyV
LLoG 1.mensedrn,feaamnal �YI1.L/I�G
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S OWNER-BUILDIiR DECLARATION
2u<Y 1 hereby affirm that 1 am exempt firm the Contractor's License Law for the
SCEfollowing Mtran.(Section 7031.5,Business and Professions Code:Any city or county
X m which requires a permit m construct,alter,improve,demolish,or repair any structure
Y-a
prior it) wm
its isce.also requires the applicant for such Permit life a signed statement h'
s that he is licensed pursuant to the provisions of the Contractor's lice rasa Low(&Pte,9 Sq. Ft. Floor Area $N%Notlon
s�$ (commencing with Section 7kXR of Division 3 of the Business and Professions Coded or
.. that he exempt therefrom and On basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant In a civil Penally of or 0 Occupancy Type
oat more than Eve hundred della.($500).
❑I.as owner of the progeny,M my employe.adds wag.is their sole compensation,
will do the work,and Ne structure is not imended or offered for sale(Sec.709,1,Business 502 717
—
and Projections Code:The Contractor's Liana law does not apply to an owner of 506 - GAS TEMe DSpeC Ions
pmpery who builds orimprovws thereon,and who doessuch work himself or through his
own employees,provided that such improvements am not intended or offered for sale.If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of com fiction,Ne owner,
builder will have the burden of proving that he did not(wild or improve for purpose of
anile I
❑1,as owner of the propert&am exclusively contracting with licensed contractors to
construct the project(See 7014,Rosiness and Professions Coded The Contractor's Li- .
cense law does not apply to an owner of property who builds or improves thenen,and
who mntmets for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
C3 I am exempt under Sec. .B&PC for maxon
owner Dole
WORKER'S COMPENSATION DECLARATION
I hereby affim,hour,penally of fc,jury one of the!.flowing drelarati ms:
I have and will nommin aCenificate of Consent m self insum for Worker's Clam
station.as provided for by Section 37(X1 of Ne Latin Code,far the performance of the
work for which this permit is issued.
vs,end will maintain Workcis Compensation Insurance,as required by Section
3700 of Ne labor Code,for the performance of the work for which this permit is issued.
My Werkef3 ompe satin remora carrier and Polity numMram: 3 C/
Carzier. < Policy Nu.:�� O(0
C RTI CATEOPE%EMI'fIONrZmwORKERS'
COMP17NSAI'[ON INSURANCE
(This section need not M completed little Permit is for one hundred dollars(S I00)
,r Icss.)
I certify that in the Performance of the work for which this Permit is issued,l shall not
employ any peon in any manner W as to MCDme subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Mcome subject to the Worker's Compensation provisions of the IaMr Cnde,you must
O z forthwith comply with such provisions or this permit shall M deemed revoked.
z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nae e is a c'maraction lending agency loo the perlmmancr of
ai 7 the work lit which this permit is issued(Sec.3W7,Civ.C.)
tel Q Lender's Name
IY Lenders Address
=1z
U 0 1 cenify that I have read this application and sum that the.leve information is
f' correct.l agree to comply with all city and county ordinances and sidle laws relating to
0 U builaling constrou.n.and hereby rimmuix mpresrmauves of this city m enter open Ne
LU alive mentioned propcny for inspection purposes.
F Chi (We)agree to save,indemnify and keep hmmlcss the City of Cupertino against
V y
liabilities,judgments,costs and expenses which may in any way seems,against said City
zin consequence of the gramingof this Niondi.
APPLICANT UNDERSTANDS AND WILL COMPLY W ITU ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Reproofs C
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the epplicanw,forum building arupant some or boodle hamrdous material
ex defined by the Cupertino Mu !pal Coale.Chapter 9.12,and the Ncalth and Safety
CnJe,Sc❑c YC525512(a)? No All roofs shall be inspected prior to any roofing material being installed.
Wilt the appficam t fuuve building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
of l,acardeus air cartrapomears as rehired by the Bay Area Air Quality Management all new materials for inspection.
coria?
❑Yes Nn
Ihavc mad the ban wsmateHats requirements under Chafer 695 of the Califor-
niallcalN&SafctyCuJe, dmo25ND,25333and25534.1 understand real Wilding
does nm camrmly have a tenant Our it is my responsibility in notify tM tceuPant of Ne
mqul a hichmustMmet toissuan.ofaCerdfcamofa anry. Signature of Applicant Date
Owner it,authorized agent O, All roof coverings to be Class "B"or better