02040026 CITY t DING DIViSiO NO CONTRACTOR-INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT N0,
11845 UPLAND WAY WATER HEATERS ONLY 02040026
OWNER'S NAME: APPLICATION SUB DATE
HARLAN SETETHE 970 E. MAIN ST, SUITE 201104/05/2002
PHONE: SANITARY NO. CONTROL NO.
(415) 566-2209
ARCHITECDENGINEER: BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
'S» I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
i=C with Sacd..7000).f Diviaion3ofthe Businessmd Prufaidmos Code.andmylismse REPLACE 50 GALLON GAS gW�ApTpER HEATER
is in full forte ane,.(B �r @0 Lf0��
,w< License Li,.
a Z ,`�
a.u Date os/A 7 Contracmr
�LL ei I ARCHITECT'S DECLARA ON DEC Ora 20 2
„g i undcrsmnd my plans shall be vud as public records
7 S O O Licensed Professional
OWNER-BUILDER DECLARATION
axi'4 1 hereby u(Srm on 11. exempt from the Contractor License Low for the �I• ® �
F?< following reason(Section]031.5.Business and 1'mfessinns Code:Any city or county L
I F❑ which requires a permit m construct,alter.improve,demolish,or repair any structure
u�3$ .pdonoits issuance also requirts Weapplicam for soh pemniuo Eleasigned"tuarent.
that(commencing
eith Secmi,70,R of
the he Re eat and Probations
Cmr9 s' , ' r a Valuation
(commencing x'ith5eciion.7(NIO)of Divi>ionJof the Repeats and Pmfmsiona Cale) i a ' 36S�O D Tr6r ,,,tr 1.S It '
or that he is exempt therefrom and the basis for the alleged eiernuion.Any violation " - `
of Section 7031.5 by nny applicant for a mnit subjttta the applitant me civil penalty
.f not more than rive hundred dollars($500L 502APNVINAL PLUMBIN ENERGY Occupaney J P
e
01,as owner of the property,or my employees with wages as their sole compensation, 606 GAP M9rT_
'-will"do(he'work:and(be swctute is not intended wr""offered for sale(Sec:]044;
Business and Profession.Code:The Cnntmcior•s License Law dna not apply to an 507 — FINAL pl ftggrp fqbspections l' - b;-
owner of property Who Wilds or improves therame.and%he Jas such work himrau
or throw h his own employees.pe velcal that such imp ovmnems arc not intended or _ _
:6ample or sale.IL ne the building p of Moo n gold wuhm one year of - `
improve for the mvne b 'IJ ill have thehuJ of proving that he did no l build or -'
improve for pumnse of mleJ.
m l he project
r jhe p open),am Basin sely d uun sion, s n.The mumate to
nstmct the deal riot
(Sec, 10 a Business and Pnt,whob Code:)The Conthe mr's „r
License Law docs not apply loan ownwith property who builds or improves t.to the
_Comma ce,Lic ns Law,. projttts.with.e.comracmr(s),IicensW pursuant.m the_
Gmmcmts License Law.. - _ .._ . ... _..__._....__...._.... _._._._.__._..._.___l_....._ ___... ..______..
s _ Oµamexempt mderSac. - .B&PC for reason
Co
. _, stet`•.,'i - ., Date' .
WORKER'S COMPENSATION DECLARATION
I hereby amrm under paral(y of imrjury one i fihe.(ollowing declamtimm:
0 1 have and will mmntvin a Caribbean,of Coneam'ro s,lf-insure for Worker's
Compensation, as.provided for by Section 37110
of the Labor Code, for the
performance of the work far which this permit is Wool. .
1 have a d will maintain Wo A s Courn,meadimbestamcii,as regmrtd b Section
of the Labor Cod forN Performance.f thework for which this f permit is
Cseed MyW kcrsC pen au Incur rice Gamer anUPofcy mbca :
� -�:
is r► I .'YdlerNn, l.J/6 SGS �% '1 h r tit ,�1 �
_..
'.:CGRTI CAI IONOFEXEMPI SATION,INSURANCE10NPROM.WORKLRS', •.I�• I. hl1'i . . .s
_ ,.. :.. _.._.__ _...............
COMI'ENSATION .. ......._._
"'(This section read out hc'mmplcad if iM1e permit is for one hundred dollars
6100)or less.)
I-I can,fy that in the performance n the work for which this permit s issued 1
Comnot employ any person n any man as m become sub3cet m the Workers' - -
Compensmion Laws of California.Date,��'
NOTICE TOAPPLICANT:the Worker's
a tteipen ing tich isew Won,of
of Labor(ion,yoou most n . .
Z becomesubjectcomply thesuch Crimes or this proruil shall the Leber CotAked, most
r mhwilh comply with such provisions or this permit shell be deemed revoked,
Q 0 !o
"CONSTRUCTIONLENDING AGENCY
r ,
'heaby ifRrn Ins there is a m.sdunion lending agency for the performance
of the work(rn which this permit is iamed sec.3097,Civ.C.)
Leder Nam . .. - ••ix .. _ .. _.__ ._ _ . _. ._ ._._ .
V�'c 1 Gen fy that I have mail this application and state that shove information is '
I, [r horrecl:1 agree in comply with all city,and county ordinances and state Iowa relating
' �.V to Wildingaastmciion.and hcaby emhorixe rept<sentutives of Niscity tommrupon
the above-mentioned property for inspection purposes. .
Lia (We) cove ve indemnify and keep Notorious the City of Cupertino against
. V) liabilities,judgments,costs am expenses which may in any way secret against said
V.z City in consequence of the gnnU- is perml0
r APPLICANT-0NDIE,
ERSTAN . NDN ,L CO'MPL hTTi ALL,�ry yTO T
' sip ICEREcuLAnovs a �J Issued b) 21 Date
g cauUc t m ? D t " Re-roofs
C d Bnedlb�the HAZiARDOUs11ATERIALf DISCLOSURE
i at r of Appli /� -•�
ni
'plicant been,Wilding occupant sore or handle h" taws ont Type of Roof.,
Copes o M n c pal Cod Chapter 9.12.and theHealth and Safety
Ede Section 2553 (a)
ores' t' All reals shall be inspected prior tto_any_roofing material being installed.
r Will the applicant.rfuture Wilding occupant use
equipmentordevices which t If a roof is instAlled'without first obtainingan'ins ection; I agree td remove
emit hazardous air cont o ed by he Bay Area Air Quality Management P g
`District, " all new materials for inspection. Applicant understands and will comply with
contaminants ,tri
❑Yea
Pp P Y...
t I. �; �� , ,�,�, , , al]'non-poini'souFce regulations:,. ,. � :
1 h' e rcaJ'Ihe hmallous mmerials mqu mmmIx under Chapter 6.95'of the
C fomty Heahh&Safn Code Sections 25505 25533 and 25534::)understand that
I fdt illi gdasnot currcanyhave atenam ih t R is my responsblty to notify the -
paneofCher mm h¢h'must be ma pot t.tss n 'faC Bc}t f,
Coca, � L,L Signature of Applicant Date
wrier or thoromd-12
rut ' ' Da/„v All roof coverings to be Class"B”orbetter"
n .
...OFFICE -- . .... .. .._. .. . ..