00100225CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BU1LDINC, ADDRESS:
PEHMI'1NO.
UST WATER HEATERS' IN.
00100[125
O\VNIiR'S ..
APPLICATION SUB DATE
SUSAN
1764 NATIONAL AVE
10/31/2000
AND
]ONE: x
SANITARY NO, CONTROL NO.
ARCHI I ECDENGINEER
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BUILDING PERMIT' INFO
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BLDG ELECT PLUMB MECH
LICENSEDCONTRACIbR'S DECLARATION
Description
I hereby alEm, shut 1 vee licensed under pravi,inm of Chapter 9 (ammnendng
.lob
,vuh.Stminn 7000)uf Diledon the liunines, and Plomc Ions Code. and my l lensc
is in full lam and d'fcd.„u
'
Licenw Claps Lie. p
Date
50 GALLON GAS WATER HEATER
ARaBTECPs'i1CLARATION
REPLACE
1 ...ersmnd my Plans us
,hall be ed as public records
I,ku,wd Prnfe."gaul
OWNER.BUILDEH DICCLARATION
I hereby alfinn ,ha, I cent exam”, from ,he CuntmmI'r:, I.iccnw ]..w far ,hc
following rmam.(Sel, a 71131.5. Business and Pmfes,ions Care: Any city or county
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which tvgnires a permit to convect. alter, improve, dcna,lhb, or repair any structure
prinr Ie, Ira issuance, it... m"arm' dac.P"Ilaue Ins such "moil or file a,igned,lalr mot
Sy. Ft. Floor Area
Valuation
that he is licensed paranmua,he pmv6iomor,hc Carrier r, Licemc Lw(Chapter 9
(commencing with Section 90X1) of Division 3 of,he Bmhu.•,s and Prom. ices, Calc)
or mum nc is cxenspt thcmliunu and the batt, liar the alleged exemption. Any violation
of section 7031.5 by any applic tar lar a permit ,objects the applicant in a civil penalty
Al)N Number
Occup-AkySType
of reimpose than five hundred dollar, (s5ao.
_
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❑fa—arrof,he pmiseny, or or, employees win ionic, videir-le cmnpenwran.
166550/4 it QlOequired Inspections '
will do ,he work, and the structure, is not imamded or altered or sale (See. 9(}00,
Ba'bw' and profession% Cade: The Contmc,m '� License Law does not apply It, an
esse, of property Who brics or improves daemon. and who doe, .,It work I pelf
n through btuwn emplo,a,. prt,,dcd dant ouch imps un amen ed lir
rf e,al for sale ¢ IL how'evec the building or impravadmart is ,old send. one year of
completion, the
5012 — FINAL PLUMBING ENERGY
impmvc tot pa'pa's of ids.).
56 -Gas rEsr
praperrc, um esdir,s%i a,mmNng suint licensedshenntraaanor, 's
❑ 1. a,ct
507 — FINRL PLUMBING
he proje
Liernselrocprajea(see.ytoaow,lite'aandPr,whobcaeo:)Tnevesdaem;.
icense, Law macs nm apply man owner of improves ,hereon.
who hulice
a conty se
and rano comma, Ino such pmjea, witb a wmnaon V licensed puauant it, the
Contractors UrndLaw.
❑lam exempt undersec ,BxrPefor this react,
Owner Date
WORKHR'S COMPENSATION DECLARATION
I herebyattire,, under penalty of psvjtay ane of the following dee larro as:
`Ito
I noe and will maims in a Certificate of Consent m self-Insure rar Worker',
Gnopauaion, u, provided for by Sectio 3900 of the Luber Code, for the
L
to
performce of the work for which,hi, permit i, iss..d.
an
❑ I have :dad will niainutio Worker', Cmnpen,ation In,umnce. a, "aim, by Section
3901 of the Luba Code, for the perfnmwnce of die wurk for which Ink permit is
issued. My Warker's Congwnxation Insurance currier and Policy number are:
Crooner. itdicy N.,
CER'IIFICA'1'[ON OP IIXEMI9ION FROM WORKERS'
COMPENSAI'1(IN INSURANCE
(11, sv,don neat)1 1 he..... ,plateal it he permit is for one hundred dollars
(S 00) or It,,.)
I cvdll, tow ice the perl'nnnunmof the work for which this permit i, usual, I
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shall no, employ any person in any manner se, as to become subject In the Workers
,
Compcnwllon Wwa of Culili,min. Darn
A,I'm:ml
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NOTICE TO APPLICAN"r: 11. after making this Certificate of Exemption. you should
bxnnmsubjecuo the Worker' a Compen,ution pre, of life Labor Craft, ymain't
forthwith comply with such provision, or this pmol, shall M deemed revokN.
CONS,RUCi'ION LENDING AGENCY
1 hereby nllirn, that them i, a construction lending agency for the Performance
of the work liar which this "email is issued (Sec, 2017. Co. C.)
[soda', Name
Lender's Address
I rfq dm, I huve mad tbiwp,dicwinn and stem ,he, he above inforamanion is
correct. I agree to comply with all city and county orminancaa and state laws scluting
In building asoma,,inn, and hereby autnorim mpmwada ives of this city to corer atom
dr, uhnvcnm.untied is for Inspcalo i pupma,.
IWe)agree to save, indemnify and keep harmlos the City o,Cor iso asaiml'
liabilities, judgments, cods and c"mr•, which may in any way accrue against said
City'a m.....mace of It, rairn, of t hi, Iwrnit.
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APPLICANTUNDERSTANDSANDWILLCOMPLYWMIALLNON-POINT
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature olNpplic:mUContmaor Date
IA%ARDOUS MATERIALS OISCLOSURE
Will d,c applicant or future building occupant stem or handle ha indoor, material
Type of Roof '
a.. defined by the apcniau Municipal Code. Chapter 9.12, and he Health soil Safety
Calc, Sermon 25532(.):
❑vert 0N
All roofs shall be inspected prior to any rooting material being installed.
Will heapplicaatorfalarehaddingo,etipmnn,,agcapnanadesiov, which
If a roof is installed without first obtaining an inspection, I agree to remove
`•mi, ha..ao aircontaminan,u, defined by ,he Bay Ana Air Quality Management
,,,Ince
all new materials for inspection. Applicant understands and will comply with
Ova` 0N
all non-point source regulations.
1 have ream the hrrankn, notanals reguiremenns under Chapin 6.'15 of the
C.liloniu 11.101 k Salcey Code, Sedum, 25515, 25533 an,d 25531. 1 tmdcrs,and thus
if the building does not currently haze a tenant, that i, is any resp rodali,y to notify the
exceri,parto of be reguimments which must he met prior to i„oanec of a C'cnilicum of
Signature of Applicant Date
All roof coverings to be Class "B" or better
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Owner Data
arnamai,emagan
OFFICE