02090156i CITY OF CUPERTINO
.
BadntNG DIVISION PERMIT
CONTRACTOR INFORMATION:'
'4,..16AWJURILL LN
WATER HEATERS ONLY s
PERMIn.090156
�fffZS' tf9AN MARY D JR AND CLYDE
970 E. MAIN ST, SUITE 200.
APPLIC61"yInDAIT 0 0 2
PHONE:
415)566-2209
SANITARY NO. CONTROL NO.
ARCHITEC IENGINEERr ';
.. ...
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
• LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmmmlam u«nsednrm
ider provisumum' Chapter 90omencing
'with
REPLACE WATER HE�.B.�y CIIp hOn
Section 7") of Division 3 of the Business and Professions Code. and my license
in full',f ens e�H
lose Lie.e /
Liiama CDole Contractor
ARCHITECT'S DEc LARATION
I. understand my plans shall be used as public manors
Licensed Profnsinst
"" OWNER-BUILDER DECLARATION
'I hateby iRrn that I am cxcmpT from the Contractor's License law for the
fo0i ving
7 O 0
$700
o amn. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to entsamet, alter, improve, demolish, or repair any structure
y MOT TO tounanchor, also occUirea the Rpp[iCRTt firstRob Permit Ilk a Signed statement -
thathelicensed the pro'.w. f L Low (Chapter9
- - _ _ _ ...-.....
Valuation
unapersett OContractor
(cnbaLm sctnn70011 3 and Potassium,
�'�•\s 7 ti\t's.. ) • S " r i. s '
or the: exemptlb
mirinniffic ,ha.Il cde ilnim
exempt iherefmm and the basis for the alleged e4cmgit to Any violation
ion dam for o permit subjmmthe applicant to a civil Malty
'of nor ion a m n iv any hundred
oat more Nan Five M1undreJ doryars astxn.
b02 A-PN
Occupancy Type
O 1, as owner of the popeny, or my employees with wages as their sok compensation,
506 - GAS TEST
�Z
ill
-will'do the work, and'tbe structure isnot intended or offered for sale (Sec. 7 W,"
- - - -
,wRUM
acid Professions Code: The Contractor's License Law does not apply to an
nspectlon5 T
.What of property Who builds or improves Thermo, and who does such work himself
or though h employees. p 'der that such rmproveissid ere not
oro,intended
;cReml fo i oIf,w h ' m 6 IJ t r p m ins sold W did not f
comply b 'id 'll h th bub of p ng that he did oat bu Id r
_ ., _ . _ _ . .. . ._.. _ _ ._ .. _.._ _
I s '
purpose
.Pro ( of salt)
ofthcpnm exotuiy s t shlccconuvarsm
comtrache project(Sm.7044Business and Professions Cade:) The, Contractor's
License Law does not apply to an owner of property who builds or improves thereon.
OC ,
. md,who contrac¢.mr.such.proiens with a contriaoot).licened pursuanm t.the
.. __ . ._.._. _......_._ ___.__.__ _ _..... _._....__....._ ,� _ _._..._...._.__.__.....___...._..... .
...... . -
C mragmrs License law. -
❑t
la pt dei Sec' - _ _ ', . H,&PCT this reason
2
�'.�', �j'3;De�
O cData „
WORKERS COMPENSATION DECLARATION
i' 1 hereby affirm under Penalty f pe i y,�ncof tIbafhlbmrwiri, J I tinny
siu�
❑ 1'havcaml wills'mainiam a Cenif,nne of Consent to self-insure for Worker's
Cimu'usaticd.'as provided for by Section 37(x1 of the Labra Calc, for the
' pe ..an. of the'wark for which this permit is issued, f
ha nd will'mainuin Worker's Compcmmiion Iniuidnce, ai require) ey $action
37110 f ,1 LdW, Code, for hetpe f m f th work f which This Permit s
issued'MyW a ornMerstion 1 -um d Policy be arc:
_
Crone.
CP.RTIFlGTI EXEMPTION L /e0��%' ''�L
�. 1, i 't 5 C� 1: `iii.+ita.'11,In i'•If f4 '). �. i %(>R.,. _ I :.i.. _ .,.............. ,.
tr
COMPENSATION INSURANCE"
obi, cu °n nccd not bc.ompleted if the permit it for one hundred dollars
ISIWI or leer), ,
'- sl tfy hsl tbe µi ,. okfr-hehth pennt :esti r'1
r, tl-, fl s'L"•Aiftt M •• ,.. .,. +_. -..
er
sh II not employ y any pc y ma a to Leann s blcn to th<IWorkers'
'
Compensation no, of California: Data
._ .. ._J .. ._ _ ._._.._ .. .. ....._.. .. _.....
ANTIf. eU meAirm Certificate
.NOTICE TOct
Code.
•"' . t' .+t
mile LuiWo you muu
fort° subject tie Nuchpr Colons
dhn proisihsoftheemed
ruolu,bu
forthwith complY'wisli such provisions Lir this permit shall be deemed rtvokrJ.
or
.. u "._ """RUC`s_. - .. .—._
c.s'CONSer,isa ON LENDING AGENCY "' -'
_ .__. .. _._ ..__. _.__. ..... ..._. ..... .. _.. _ _ ._...
'" ts'• '"'ts •'t s
" Ihertar
thus dtai'isaissued construction 3097.ngagency for the perfurnwncedthil'
work which
Lind"' No"which this permit . issued ISne: 4(197, Civ. C.1
lend . Address - r
1 n Thai I have ,ad tti .applicationand tat that the above information is
/
eotrea I ,,,a t comply with all c ry and room, N' nc s and t tc s m Icing
n
g t nrIt by'th r m a fth. 'ryt n¢r upon
'held
ed yf rim
'he M c t eJI pendf pea p ry
h Thi Cdy of Cupertino against
(Wej agree io.sme, indemnify1, and keepwhich
Is 11 e. judgments, nista and which may-in any way accrvc eguipss said
nou, in
J .i ns
Cisy inchnsequence of the griming of this ermiv
SO RpCANT UNDERS7AN'D5� •' 30MFI' M'1'fH ALL NOs TORT
-'t_
Issued by� Date
SOUXCEkEGL'LATIONS. 1' Q
. Stimalate°fAppli.mfiCommclo,One:,,
Re-roofs
ALIROOU-S \TERIALSDISCOSURE
'
W Iapplicant f tort buatg panttoreLorh:uul "a,
Ty..e. ,,,.....
,t
f]
Je( by the Cup n hip1 Core. Chapter 9.12, and theHealth and Safety
Cm (al
t i..
;p„in
°'
be.
a.l.l.e..d....._,
A1LroofsR
sOhOa eei�ns�pcce d ri`o'r-tt_o'
anty..'r_io.ofing.._materialg.ine.
Will the.,pliant or future building occupant use equipment or &,h,,, which
..."..._....
If a roof is installed without first obtaining an inspectiobl I'agree tolremove
roof hazardous air contaminants as def ned by she Bay Art A Quality Management
District?,:.�
,
all new materials for inspection. Applicant understands and will comply with _.
❑Yes r-:: - .'f]Jiet"_•,
.. ..,. . _. .. ...
all non-point source regu]ahons.Xlp3i -
s'I have read the haaaNdu. moicriah requirements under Chapter 6.95 of the
California Hca3sh & Safety Code, Sections 25505, 25533 and 25534. 1 undersmnd thin
'rhheb'IJ gdnesn tc rte sly hareaten t th t t my po. blity th nhufy the
_
dccupa t f them nts hich must be mei pnor w, -. apc f a C ifcat • of
°" `y
9�Z
Signature of Applicant Date
All roof coverings to be Class `B" or'bettell
ow ra,awhn .agent
::_ r I OFFICE . . .. ........._...