00050182 e CITY OF�CUPERTINO CONTRACTOR INFORMATION:
PERMIT
BUILDINGAIVIET42 WILKINSON AV JUST WATER HEATERS IWMITNO. -
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OWNER'SN'1"_'DRENZET MONTE D AND REBECCA E 1764 NATIONAL AVE APPLICATION SUB OAT H
HONE: SANITARY NO. CONTROL NO.
G®ZARCIETECUEN'GINEER: BUILDING PERMI I'INFO
.00 (510) 293-9901 BLDG ELECT PLUMB MECH
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H- LICENSED CONTRACTOR'S DECLARATION Job Description
p S=G1 hereby aflinn men I um licensed under PKb
rrvns of Chapter 9(commencing
F C w with Soetion 7000)(,f Divi I3 of the iminuss and Not ..I is Code,and any loans,
ay.Y E is in full force and effect.
zea Liceme Class Lim.b
m U Dale Conlocl
de a y ARCHITECI"S DECLARAI ION
t—O n 1 understand my plain sba0 be used a
Ns Public mcrnds
cc.a;, REPLACE 40 GALLON WATER HEATER
w i O Liccnmd Pocr,sional
c a e,J OWNFIURU1LDER DECLARATION
I hereby aflinn that I man estop,from the Contractor's License Law for the
S< following mason.rsttni(,n 703 1.5,business and Ptofnsios Code Any city or county
xF o which reg pe on,, .t I air,, P J fish par any strucmrt
waw prion , is also q theapplicantf such Permits fl gedoalcment
a. - horn d pon%cantI the provimorvi(ifn Counnichat's Limn Law(Chapter 9 Sq. Ft. Floor Area Valuation
m cntnuewithscm,am7aw1ofDivision3oftheRt"inm,rand111 "car,Code) $744
or in.,he is esempt derefrom and the Nei,for the alleged exemption.Any vioW ion
of Section 7031.5 by any applieaml for a permit subjects the app,icanno a civil Penalty
of ton Im,ae tiara Ree hundred dollars(550X)). APirtyi�'71. OW Occupancy Type
01,as owner of the propi mY employers with wngcs as their sole compensation,
will do the work,and the structure Is not imntded or(,listed fie sale(Sec.7(104,
Uusiucss and I'mm,,ions conn The Cmurri:,livens Law does not apply n,an Required Inspections
orr of pmpenY Who builds tar improves thereon,and who tiles such work himself
through ms awn r, payees.provided that such improvements art not intended or
ol'1'cmd for sale.It:however,the building in ima it"Ina nl Is sold within one year of
completion f tbeswnmr(builed'rwill have lhelordnof prnvinglhm hedid not build or 502 — FINAL PLUMBING ENERGY
ams pvpose i
❑has ,.a,, Iffive pmpeny.arae.ecu,ivaycomment,will,rcenmdeongacam,at 506 — GAS TEST
construct the prujce,(Sec.]DW,Business and Professions Gds:)The Conmemor's 507 — FINAL PLUMBING
Licinic Lewdoes not apply In an owner of,n Terly who huild or imam es thereon.
:utd who contracts tar such projects with u contmemr(s) licensed pursumn to(lie
CnmmiI License Law.
0 I ma esenin under Sec .B&PC matins mann
Owner Date
WORKER'S COMPENSATION DGCLARAI'ION
1 hereby of l'In under p,oulty ul perjury nuc of the lot kovi ng deelumdonr,
❑ 1 have and will nminmin a Ccraicate of Consent to self-insure for Worker's O
Cmnpeasadnn, ns pmvideJ for by Section 3700 E the Labor Code, lin the
performance of the work for which This permit is issued.
❑1 have II will Inaialain Walker's Compensalimn Insurance,Its muciret by Section
3700 of the LInso Code,lin the performance of the work for which Ibis Fermi,is
issued.My WmAer's Compensation Insurance carrier and Policy number am:
Car,In,: Policy No.:
CERTIPICA'I'ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis scultor need not be completed if the permit is for ane hundred dollen
Is Iq)or IcuJ
I verniv that in the Fcrli,mwuse of O e work for which(his Iconic is isuucd.I
shot]not empty any person in any manner so as to hecome subject it,the Workers
Compemninn Laws of Coliform..Date
Applicant
NR YETCE TO APPLICANT:If.(,fret making this Cendir m of Iiscm,linn,yru should
hemnme smbjca m the Worker',Cmmpcnsminn provotar,of rbc labor Cole,you mus
Q 0 fnnhwith comply with such provisions or this Iwrmit shall he dscmed revoked.
z CONST RUCTION LENDING AGENCY
a71 hereby affirm that them o It construction lending agency for the performance
W d the wed norwhlch This panto is issued(sec 3097,Civ.Cd
6. C Lenders Name
.7 Z LenJet's Address
V Q 1 certify Ihat I have re:W this uPpa,mia I and state den the above informal on is
W. [.. correct.I agree to comply with all city and county ordinances and state laws minting
Q [) Io hailding constmetion.and hereby:nfinanee mpresentatrsys of this city to enter np,n
W the above.ltwntinned amamty Em inspection Pmlroses.
Q. (We).,me to ave.indemnity told keep females,be City of Captain.a,mum, -
(n liabilities,judgments,costs and eslwnxs which may in any way accrue agains said
V 7i Clly In cor"I'Lonce of me gnmtln,of des,...m.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date Sit `2 ) —�/'�
SOURCE REGULATIONS, y'
signameor A,ii,mhcommcom Dec Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicaw or future building occupant sore or handle hamtdows material Type of Roof
o dcfneJ by the Cnlnrinn Municipal Code,Chupwr,9,12,and the Hsa11h and Safely
Code,Srstion
OYrs 25532(x)^ 0N
All roofs shall be inspected prior to any roofing material being installed.
Wise the applicam ,,store building necop of ace equipment tar devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit harvdous xI,containments as dcGned by the Ifuy Area Air Ganda,Management
Dialnerr all new materials for inspection. Applicant understands and will comply with
❑Tics ElNo all non-point source regulations.
1 hove read the hueadous materials requirements under Chapter 6,95 of the
GII'd(,rain IF,hb&Safety Cods,Sections 25505.255.13 and 25531 1.,ad...t,....I that
rich,hulk ing Jocs not correctly have n mmwn,Inst it is my responsibility to ratify the '
occupant of the requirements which Imus se me,prim m issuance of a Ceniticme of
Wupmey . Signature of Applicant Date
Owner,,,must ri,ed agent Dale All roof coverings to be Class "B" or better
OFFICE