00080055 CITY OF CUPERTINO - PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION:r-
RUIhU1NG ADDRESS:
7948 WOODLARK WY HOT WATER INC SANITARY NO.m 'gPg10c In�I 81JBMITTALDAT
OWNER'S NAME:
NIC CONfROLg
PHONE: ] jet IN 2531 GRACELAND AV 08/08/2000
ARCHITECT/hNGINEER (650)298-8494 BULUING PERMIT INFO
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zZ„E Ihereby aRrn LICENSED CONTRACTOR
li eased trocar oro��ofC ou.9 t<mamurcing Job Description
F__u�i with Sation]I100)-f Division3of Ne Busincesvd Prokmiom Cade.ad mYlianw is
�xf in mllforceand «e” t' REPLACE WATER HEATER —
y i n u can.Class unit
Dam Co..
n p 3 ARCHITECTS DECLARATION
f I undenrend my plana shall be used as public roads
Licmaed Professional
^_ OWNER-BUB.DER DECLARATION O
C z a 1 hereby,(tied inn 1 am exempt from the Conuomr s License Law for Inc
^L❑ following mason(Section 7031.3,Buairess arm awl derws Cade:My an i'county
�3 m
which eegnires.amdt m<omwa after,improve.demahm.sir report err atmcmrc Sy. FL Floor Area Values Ion
primohsisauencnefsarequires the iiionsOffa Connotations
file,signed lanced
that M is lianxe puesmm to the Provisions of the Conrrarofs License law(CTupter 9
(eomtmnciug with SiNdim70(a0)of Division 3 ofthe Business and Profession.Code)a APN Number Occupancy TM6
that he is exempt Neeefmm ad thc basis for the alleged exemption.My viobdon of
Section]031.3 by any appllcmt for.permit aubjab dee applicant W.civil antlry of
not en-ee Nen five hundred dollars(5300).
�1,as owns-(lyse propcny,wmy employees with wags uNeir role compemadon, 662040'a1662040ft4aimo Inspections
witI prthework,ands: mumureisnot imeMdm o&md fmsilo(Ss.t aI.Bn;nu
am Professions Cee:iTh,mp Con them'a,and w taw don not apply s if avmr of
his
employees,Primpmva Nachnad sach cut
kdd OF Or through 106 — SEWER 8 WATER
his own employees,Provided than Fsuchrow imaovemrnu thin nd intended c nRcml fm
sde.lf,however,the building or impmvcrmmis Bola within one year ofcompletion,Nc - 202 — UNDERFLOOR PLUMBING
war-
W;ederwillWn do,bumentofaavingthat hedid not Wild mimpmvafor pars- 301 — ROUGH PLUMBING
post-f sale.).
❑I,m owmr of the rapers,the exclusively camrradng with licenced coraaacmry m 302 — TUB & OR SHOWER
contract the pmjecl(Ss.7044.Baairusa ad Professiam CW.:)The Cnnuacaor.u-
cerad Use does not apply to an owner of Property who builds or im,novesi therson.and 502 — FINAL PLUMBING ENERGY
who conhacls for such prejrcu with a con excmds)licensed pursuant to the Coni seals
IJccnse" .. - 506 — GAS TEST
❑I rum exempt under so. .Bepefarthisreasme 507 — FINAL PLUMBING
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under PenPenaltyof perjury.of du s W
following dauaa:❑l have and will mountains
Certificate of Consent to self-insure forWorke'sComan-
smi m,as Provided for by Section 3700 of the Labor Code,for Ne per.—of the
work for which this pemdt is issued.
❑1 have and will m timain Worker's Compensation Insurance,as required by Section
37W of dm Isom Cab,for the pail—e-flys,wart for which this remit is issued.
My Winner Comammion Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Irvin orcum rod not be completed if the pami t is for ms,hurled Loners(SIM)
or les..)
1 cenify that in the performance of the work for which this permit is issued,l Nall
nd employ any arson in any monde so mm become subject to Ne Workers Compen-
sation Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after meting this Certificate of Exemption,you should
been.subject to the wroonea Compensation Provisions or Ne Isbo.Code.you most
forthwith comply with such provisions or Nis permit shall M de and revoke.
CONSTRUCTION LENDING AGENCY
0IherebY alEtm Ow Nert is vcomwcdon lending egeuy for dtepMomuse of
Z
thew
fm which thea permit is i.aud(ger.]09],Civ.C.)
Iedsls Name
yc ledcr' rtss
Ad
I
Iz] certify that I have read Ni.y am l coon rd dlite that Ne•have w,,mining is
Il cared.I ages tc comply withill city W plumy ntaieuma lid elite laws relating m
s7. z itba'a.mum construction,and hcmos,ecuuiamprcacnutivesnf Nis city to coot upon the
I, 0 abmvc(Wa)a re propnty for imacUal laup ha.
W F (We),gra m live,indemnify and kap ha4mlcne the City or Cupertino against
Q 4.) liabillues,jdgrsnu,cowls ad examat'which may in any way rsnse Minn.,said City
�... W in coocip.l a of Na granting of this permit.
F+. p1, APPLICANT UNDERSTANDS AND WILL COM PLY WITH ALL NONPOINT
tZI WURCERCGMAfIONS.
uz
Signature of ApplicaroCo muctor Dar
HAZARDOUS MATERIALS DISCLOSURE -
WillNevalicadorfutureWildingoccup.ntmmsorhadlehaIDrd-usmaoflil Re-roofs
as defined by the Cupertino Municipal Cade,Chapter 9.12,ad the Hand,and Sarety Type of Roof
Code.Swim.n532(a)] yP
❑Yes ONO
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit havrdoua lir emaxa imam as AeOmd by Nc Bay Arca Au Quality Magemand installed. If a roof is Installed without first obtaining an inspection
Dome,? I agree to remove all new materials for inspection. Applicant
Yes NO
un d
Lha red NeM1nraanmamdalaregairtmtmlsmdaL„apta693-f NeG.li- erstands and will comply with all non point source regulations.
(undo gdoes n Safety Code,eatiom t,that,23333 and 23334.I to azsmnd Net if the
ouildin8das not currently love a mn.nl.that it is my mamiMliry,o ndifY the ampant
of the eeyuircmrsu wNch dun be own pea m uauaoe of v Cenifinu of Occupthwy. -
Signature of Applicant Date
[honer sir euNorizd agent Dau
All roof coverings to be Class"B”or better
OFFICE