01120045 CITY OF CUDPERTONNO
BUILDING PERMIT CONTRACTOR INFORMATION:
BGfn"6419R ALLACE DR WATER HEATERS ONLY PERMI3'NO. 01120045
" 2T'7,*V`80N ORWIN D AND ELEANOR P 970 E. MAIN ST, SUITE 2 ' T!fA7lgTV'ff b1
`= PHonE:
(415) 566-2209 SANITARY NO CONTROL NO,
WOO ARCHITECTIENGWEER: BUILDING PERMIT INTO
U 0r BLDG ELECT PLUMB MECH
6 h 2 LICENSED CONTRACTOR'S DECLARATION ti
iin� Ihereby affirm that l con licensed under provisions of Chaver 9(commencing REPLACE 50 GALLJPNl RIGATER HEATER
m_+� with Station 70W)of Division 3 ofthc Business and Pn,fosimm Code and my license
m<: kin full force unJj�1
see License CI,vy Liea 3 3
o Dae_.)/ Cummaor
i 3 y AR fiat be a UECLARATI N
m; 1 und<rsmnd my plans nhsll be used as public rtanrds
i a4p Licensed Pn+leminnal
OWNER-BUILDER DECLARATION
I heresy alto»mal 1 cBusin from the Co,iwry C's License Law for the $700
t- followingrtaxoa permit
]031s,Business and Professions Ca de:Any citymcounty
E o
whichrt q p tart s t n p d I'it t in repair any xwaure
3$ prion r also requires thecionsapplicant f h in 't Licenssigned statement -- -(that commercial,
.licensed p '6o a theP (Chapter
e nn Carlini t eLanxeLaw cna t 9 g r®yd .A,�f , b'v�' , , Valuation..
gem a withSamoanmar ]OW) fhe Division 3 fm l Business ad Professors Code) ' syr I + ` - ; ,
or S m he is exempt therefrom one the ,a fiction alleged dement m Any violation '
of ration a than
veany applicant Tor a cermit subkas rhe applicant to a civil penalty
or nor more man five hundred smears(SSW), 50APNNIldiinlikhL PLUMBIliG ENE occupancy Type
❑l,as owner none mr+ceny,ormy empmymx wilt wage,o dati,wle compenvron., 506 - GAS TEST
mill'do'the-work,and the'shuuum is not intended or offered for sale(Sec.7014.
Business and Professions Code:The CanalLicense Low docs not apply to an peCllGn$
orthrough
owner of property Who builds or animists thereon,and who does such work himself
or cirdfor his own however.M provided that such improvements are not amended of
dlfded for rale.If;hbwoeCihe building or Ira'- � tie sold within one � f
! ern of
yearo
oprove for the ownerhuilder will have me harden o!proving that he did not Wild or
mvtn,•e for namm.e nr xale.�. CC p�igg pp I
. .. .. . _. _ ... FIlWP-Y16�IC® . _ .._ .
- ❑1,m owner none p(Sec.71 an Badness a cmnracung whh 8anmd nom Contractor
1. . .
construct the does
project free.]044.Business arta Professions Code:)The m,tram i
ad h Law dote nm apply Loon owner of properly who builds rew 0ercnn,
and wM10 comracu for wen prnmte with a ern em z,licensed pnrsaant ro the —JAN 0 3 2002
_ 01 am exe pt undetams,
❑1 em exempt under Tao .8&P C for This reason
Droner Date
W' BUILDING
WORKER'S COMPENSATION DECLARATION
' t
1 hereby affirm under penalty of perjury one of the following declarations:
0 ❑ 1 have and will maintain a Cenificme of Current to self-in om for worker's
Compensation, is prm.iried her by Section 37W of the Lubar Code, for the
performance of the work Inv which this permit is issued.
T74.have
sad will un inain Worker's Compensation Imumance,as required by Section
of the Labor Gde;for the performance of the workfor which this permit is
issued My Worker's CompensationqInsurancecarrier and Policy number ora +•
. . carie -ILe PmteyN ./.5/62(,5-0%� t" ',, s
CERTIFICATION OF EXEMPTION'FROM WORKERS' ' r -
_ COMPENSATION INSURANCE'
(This'scetion need not 4 completed if the permit is for one hundred dollars
($100)or less) .
_ .. -
1 certify that in the n in any manner
the work for which this permit a issued.I
shut]Com our
employ any pawn in o. manner so uz to become subject m the workers
Compcnsmion Lo,vs or Culifomia.Dine
Applicant i
NOTICE TO APo the Worker s after Compensation
this Cisions of
Labor Code.you most become subject L me surker'e Compnor this pnhanitsall the Luber Code.you coact
Q 0 forthwith comply with such provisions or this permit shall W deemed mvokcd.
Z ^ CONSTRUCTION LENDING AGENCY
1 hereby afiini that mere is a construction lending agency tar the performance '
f11 mdse work for which this pejmit is i.uued(Sec.3WL Civ.C.)
L Q Lender's Name
ZD Z Leader's Address -
U O I certify that I hene xi l this application and state tam the above infurmairm is
Iy [.+ emirro.1 agree to comply with ail city and county ordinances and nate laws relating
0 V to Wilding construction:and hereby amhoriee representatives of this city L enter upon
>„ Is] the above
>, on,ti edpmwcny for nopcion purposes
CIL. (Wo)agree
to save.indemnify and keep .
ss the City of Cupertino against
Vi l iabilltles,judgments,costs and expenses which may in any way acerae again said
V Z City in consequence of the granting of this permit.
^' APPLICANT UNDERSTAN SAND WILL COMPLY WITH ALL NON-„'s,,pppw
SOURCE REGULATION” �� �� Issued by: Date 2r��Ql
Signmum mAi,i icanuci norm t ",'. I Date/B Re-roofs
., HAZARDO S MATERIALS DISCLOSURE
will tee epphcare or mare building occupant stere or handle humidities material _ Type of Roof .... – .. . .. .
as difined b5 the Cupertino M 'pal Cha 'Chapter 9.12.and the Health and Safety .... ... .. . . - .. ... -
Com,Section 21532out?
t !
°Yee '.° _ All roofs shall be inspected prior to any roofing material being.installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hwardous air contaminants as defined by the Bay Area Air Quality Manalltri
littler, all new materials for inspection. Applicant understands and will comply with
ovee all nori-point source regulations.
1 have read the hmardou.i materials requirement,under Chapar 6.95 of the
Califomin Health&Safety Code.Sections 25505.25533 and 25534.1 understand that e
'
The building does not cuven0y have a tenant.that it is my reaponsibilky to notify the
cecupanr of the requirements which must be met prior to issuance of a Cenificale of
Occupancy (r/J
Signature of Applicant Date
w` Wmedag Date All roof coverings to be Class"B" or better
OFFICE- .. .. _. -