01040100 CITY OF CUPF,R'1'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: 1'IiRbfll'NO.
W54 IIERNIE QT HnT WATER INC L711 LA401 00
OWNER'S NAME; APPLICATION SUB DATE
• PHONE; SANITARY NO. CONTROL NO.
7
Mal ARCHITEC 'ENGINEER: BUILDING PERMIT INFO
BLDG ELECT I'LUMII MECH
Fa;� r—I
dN
ti= LICIthan ID Q)NTRACfOR'S IIHCLA RA TION
z m Ihereby 70a1B.1'mmImhh Heenmdmenet proviniomm'Chanter9cammauing Job Description
Oml-w with Sttlhro]IMat effect. on3ofine Busines.anJ l'mfmsiunr Cade.and mylianm
Elx-a LicensheClas Pat i. « REPLACE WATER HEATER.
O
�6'LL-O,a m� Dae
ARCHITECT'S DECLARATION ION
1 understand myplas shall ie oJ ns Public neroNs
rteil a.p O Lirah,cJ Profmninm
w oz OWNER-❑Ull.DliR..i DECLARATION
1 me...at ocl that I sun cncmnl Ii'ohn IP, Qon,...Code:
a :Any t... Int the
I_te wfinhich re uare.s a eorlit t 7031.5.ct.alter. :ted improve.
de ions h.or Any city nr county
,tea Phich)equina a pemso ec comweL altar.improve.h perea,h,or repair any alramare
w3m prinnoiucensedc, ,a rcyuireethe visiu-applicant forthe sucContractor
oElea,i ave honer9
anernent
mnloeincingisdnSecitelt:000)lh,Of�ivbiu:llnn lieBusinexurmkl.awCasra Sy. FI. Floor Area Valuation
ox that he is a with Sation om and
Division 3 or BIN le enc.a and iProfessions. nyviCold
or that he i,exempt therefrom and the basis for the alleged exemption.Any violation
Of Section 7031.5 by any a,liean,fern Penni,,subjects the a,dicein to a is l penalty
ofnnDoth no live hundreddobar,Sift)). APN Number Occupancy ype
❑1,us owner of the property,of my employees with wages m their salt,enmpemntion.
will in The Park.anti the,hucmm Is not intended or edc.ed nn talo(See.70114. s.
132204
Bacinec,and Pmfeenia is Code:'Ihe Cammct.",License I.P.lows not apply In an eyatrcd Inspections
,,, r of pra,my Who Mhild,m n n ow,thereon,and vena dues,ash wad himself
it mngh his awn employee,.P.ovid,d That sack imp ravemen,are.,it intended..) 502 — FINAL PLUMBING ENERGY
olre,,cl tot sale.11:now �,oto building a mphr� mu is within one yea ar
iompfelian,the awner-hnilJcr will have the haNcn of proving that he did nal build or 506 — GAS TEST
mprove far purpme of,mea.
❑I.as thnrec.7 1 :ivy esbwitf d acnnro, 507 — FINAL PLUMBING
Unet t the n l el Ib ]Ina I4 ' s J e f..on,Cade:)) np C m '.
se 1 1 ,apply, of property who bui1J. p ,t it)the
cul - Thr I t i0 10 licensedpot a the
D I.,it ors License law.
❑ am exempt uMer Sec. ,B k 1'C for this..an �
(Iwncr Date J �1
WfINKER'S COMP Date 0NIIHCLARA'fION
I hereby eflimt ander penalty of perjury one of the Iidlnwing dederat—o: O�
_� ❑ I have and will maintain a Certificate of Consent m,elf-inalie fm Worker',
Compensation, as provided for by Section 310() of the labor Code, for the
parlbnnancc of the w111k pu 111X10 this pmol,Is ircunl.
❑I haw and will maintain Wader's Compenuti m Insurance.as required by Section
3708 of the l.aMe Code,fur the performance oI'the work for which this Penni,is
mel.My Wndds Cn u,sncmion Ill curnines,currier and Policy anoher ore:
carder: Policy No.;
CHR'I'I FICN4ON Or CXI?MPNON PROM WORKERS'
COMPE'NSNI ON INSURANCE'
('Do wcion sued no,he ounudercd if the Ix'.oil i,for one hundred dollns
($tall nr Ics:)
I certify that in the perRnmsnce of the work for w hick this Permit in issued.I
shall nu,employ any pcoon in any manner s to become subject bit the Wurkeri
Compcn,mlon Lawn of Civifon.W.Damon sans
Applicant
NUI'ICE TO APPLICAN"C If,alter making,hi,Cenifcate of 1?xcmp,ion,you should
Z baunncsvhiem Bo the Worked,Cea..ca,mion Pru it..is od she Labe.0.1e,yut non
p p forthwith comply with such Itm
vision,nr this per-un,shall be deemed revok.1
Z
F ^ CONSTRUCTION LENDING AGENCY
} 1 Denby ishirn that then is In caned nation I0 7,C aged,y far the perlimnana
Lean the work for whish this permit is issued(Sec.4119],Civ,GI
0. Q
Leander',Num,
LaWcr'.c AdJrenn
V 0 I artily that I have mad this applicmlou and state that the above information is
ed,rest.I agree to comply with all city and county Ordinances and state laws mla,ing
mbaildinge.n.dncnou,INN hchxby and....rcmpmcnsatiw,nrlP"aym"'I"upon _
} the aMvomend cd Property Int inspection purpwe,.
F 0. (WO agree to save,indemnify and kap haradess the City of Cupe'nina against
V) I"Ibilllic"lul"Pents,......end expcme,which may In any way accrue against said
V Z City in came,ucnce of flegranting of Ili,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' Issued by: Date
SOURCE REGULATIONS. y'
Signature of ApplicinbCnrttmcmr Dan Re-roofs
HAZARDOUS MAI FRIALS DISCLOSURE
Will the applicant Or future building dccnlmm stare or Dandle haaallou,nettedal Type of Roof
ro defined by the C l,arfi n Municipal Gale,Chapler 1)12,unit she I Imnth and Safety
Code.Section 25532Im^
❑Yea 0 N All roofs shall be inspected prior to any roofing material being installed.
Will(lie applicant(it future buildhig Occupant use equinuclut Or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hva.Jouc air e.mtamirmnts as defined by tits B,Area Air Quality Manugemen,
Dnlriarr all new materials for inspection. Applicant understands and will comply with
0Y0° MNu all non-point source regulations:
I have read the haiardous mmerials requiremmriu under Charter 6.95 of the
Cal train I lcalth ic Safety Coals,Sec,int.25505.25533 and 25534.1 unJentand'hat
it the budding doe,nal cume my have annual,tel it is Illy.spunsibllity m anally the
.ecupam of the co meomcnt,which nm,t be mm prim nit issuancew P Cer ircate of
Occupancy. Signature of Applicant Date
ow net or committed agent Date All roof coverings to be Class "B" or better
OFFICE