01040029 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
L 1
(IWNEWS NAME: APPLICATION SUB DAI13
rith
JONG: SANITARY NO. - CONTROL NO.
(F.901 PC)A—A4q4nOOTEC VEN(J N HIiR: BUILDING FERM I'r INFO
y. BLDG VLCCI' PLUMB MLCH
co
oor6 y5 z ce sED cu renaroR s DIICLnanrlDN Job Descnp[lon
1 hereby a,n r'no I am licensed under Prvisions of Chapter 9 tcommendng
PEf-. ction]pXgof Didsiun 3nfthe Business and pvdcssion,Code,turdmy I ieeme
is mfull fora and infect.
s Lecmechol [.it.a REPLACE WATER HE TER.
°i o a o Date Contmeh,
ARCHI'I ECT'S DECLARATION
1 understand my plans,hall Itc used as public records
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❑ hicenwJ I'rnlcssiunnl
a.Goo
Oe,M1'Iarn exempt
AER DECLARATION
Cr TION
1 hereby affect he,1 am esemP,freta the Commvmr'a License Low for the /
Z a following requires,
a fseedmt]o s,5, t,alne,s and vet.deeWn,Code:Any city err county
p which mythLv e perm;)to umslmcL uhe9ln,pmva,dvnnralish,or rcpvr any structure
u3� ptinr,oslien,m Glu„cyuitlwpmepprcamwe Ctjnterltdunlien. iUe(Chapneitl
— lf
rhanceucing,dbScnuntmnthuIDi isin3of,he tactnrsueenKl�won,Crry Sy. FL Floor Area Valuation .
(col,olie lfg with&"'I]IXXnof he Nei, 3oflite IfusineannJProfessions Calc)
+r hal he in tart Ihacl'nnn and,M1e basin to,fhuJlegcd uemplinn.ony viulmion
of Section 7031.5 by ony applicant for a perntit subjects the applicant f,a civil penalty
nfno,marethan five hundred dollars l DWl APN Number . Occupancy pe
❑I.n,ovine,of the pro,rfY,ormy employer,with wage,a.,heir...se mlvn,aion.
will do the work.t I the Graclnce v nal Intended m'offered ror Bale ISen.7W4' - -530�36Business and Profession,C,da:row Contra fors License Law does not apply to an Required Inspections ,
owner of property Who builds or improves herself,and who dove aucM1 work himself
n r n rough his owco,ployees,pro,ided that such hopmvemeat,are net intended or 502 — FINAL PLUMBING ENERGY
.11"al to,sale.II;however.the building o,nnpn,sconce'is sold within one ran,of
completion.he(ovenlvilder will have he burden rain pmving,hut he did on build nr 506 — GAS TEST
imps a Bir puryosc nr sale.).
❑Las of hepn,perty.n xclttsivclyc, acrtngw,hfnntwdcommcmesm 507 —, FINAL PLUMBING
,mullet Law
ne,no(sae 1tw1 Rnsincss property
opervfessirane G,l,, Iltc vet hectors -
and who
Low tract um apply to on owner of a contra who bunds se impost IM1to the
Cad Tact elfntmrn for such projects with a amu:v¢,gs)licensed Punuam m the
Contmnur,Licm,se Law.
❑lran cxen,pt undo Sas .IIB I'C lin Otis rcasun
Owner Date -
WORKER'S COMPENSATION DECLARATION
1 hereby afflict under penalty cf perjury one ill the following red arufinto
❑ 1 bate and will maintain u Certificate of Consent m wlf-insure for Worker'. -
Coatpensnfon, as prodded ror by Seen... 3701, of the Lahor Code, for the
perlm
ianncc of be work tar wI,i,h this permit is isxued,
❑I have and will n amain Worker's Compensation Inwmnce,ns«yuifed I+y Section
J'RX)nl(lie Lubar Codes fm the perfnrtnunce of the work for which this crich is -
cuedMyWorker sConTivi rtion Insoruncc carrier and Pol icy nutnRr are:
Carrier, Policy No:
CERT IFICATION OF EXI7NH,r ON FROM WORKERS'
COMI'ENSAI'ION INSURANCE
mi s section need no,M1e completed if,he recoil is for one hundred dollars
IS I IX)or let.)
1 rectify that in the pcdoncona of the work lin which this penni,is iewed,I
shall not employ ally pear,n in any,remner w as tat heasme subject to,he Worl:en
Compenmtion Law,of Culiframfu.Dole
Afflicupf
NonCE,0 APPLICANT 11;offer making tills CuNtieate nlEtc Prior,You should
become subject it)he Workers Compenmtion plus ion,ofhe Lather Code.you must
zQ O
Inches i,h comply with such provisions or this cnon shall be decked revoked.
tit CONST 141JC'NON LENDING AG17NCY
I herchs,utlirunhat the.is a consa„nion lending agency for the performanec
fJl of he work for which,his Penni,i,issued(Sec.3107.Civ.C.)
[� Lnic,S plans,
5 z Lendrr•,Address
U Q I clarify that I have mad this application and state that the above information i,
W E., nnm.I agotree et ccity with all mry:cul county onfitunccs and state laws relating
Qr_) mI IJlttgennetru lian,nnd hereby vuthofi're nprewnlufiven ofthle city lnente,olon
±, W the ab,vcme,nloned pmpeny for inspection pmq,w,
p., a (We)agree w save.indemnify and keep harmle,o he City ofCuNcinn agroot
fA liabilities,inducers,coos and c,,l ,which may in any way accuse against said
U z Cay In cnncyuencc of he'muting al'to,permn.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCR REGULATIONS, y'
Signature of AppllvuttVContraclor Date - Re-roofs
- IIALAKOOUS MAI'IBn ALS DISCLOSURE
Will tine aplifienot or future building oaupmn tont in,handle ha ardou,matetd Type of Roof
as defined by,he Cupertino hllonerpal Code,Chapmr 9.13,and be health and Safety
Cale,Section 25532(u)'r
El yes 0 N All roofs shall be inspected prior to any roofing material being installed.
NSB the appfiewo or forum huildin,u,apan,use nrvimnent o,de,it which If a roof is installed without first obtaining an inspection, I agree to remove
not hxfardaus air comuminunn m defined by the Buy Area Air Quality Management
)iada] all new materials for inspection. ,Applicant understands and will comply with
0`'es 11No all non-point source regulations.
L
e read the hazardous materials requirements under Chapter N95 of the
ratio It Stale y Codc.Sell 25511.5,25,533 tai 2553♦.I malcrstand full
g Jncs not cun'cnJy hove a tenant,:hut 11 is in"rn,p9nnihllily In notlly lite
,hc ,,pimmen6 which mull be mel prior,a lesuan.cof a Certificate of
Signature of Applicant Date
hodun stem D:,fc All roof coverings to be Class `B'• or better
OFFICE