03020086CITY OF CUPERTINO
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cONT�C.""ORU
BUILDING DIVISION PERMIT x
ah �W'wer, FORMATIONN
BUILDINGADDRESs:
HOT WATER INC
PERMIT NO.
1125 YORKSHIRE DR
ER'SNAME:
2531 GRACELAND 'AVE
PEaMrr tssD
MURDOCK ROSAMOND E
E:
(650)298.8494
SANITARY NO. LNO.
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BURAHNO PERMIT INFO
ARCNTTECIENOINEER:
BLDG ELECT PLUMB MECN
LICENSED CON7AAC10R'S DECLARATION
job Description
I hemby efRrm that 1 am licensed under pmvislun, of Chepmr 9 (mmmcndng
with Section ]OTD) of DlNdon 3 of the Budnraeand Prefcuiosa Code, end my license la
� yL3G/�
I n fullforce mdeR ,_Commute
REPLACE. WATER HEATER
Ucense Clg Lia R
Dose
ARCHITECTS DECLARATION
FI g� n /� a E D
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I undersunJ my phos ahtll be ugod u Puhll<rcemM
Y— a �.YI N''� /a ,
[e
fCO,_2 6 2003
f GG vv
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby AM. Nn i em exempt from the Convector's License Lew for the
following mason. (Section )1131.5, Business and Professions Code: Any city or county
which require, a Israeli to carousel. elle(. WpIOVe, demolish, of mpelr my MWOUR,
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! poor 0 its Issuance. sun mquim, the ePPImmI for such permit m file A clod summcm�[11aLlon
9
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,
' that he is licensed pursuant to the provisions of the Counselor& License law(Chapter
�b UU UU
(commencing with Section 700M of Division 3 of the Business and Profwions Code).1
. that he in esempt therefrom and the bur. fm the Alleged exemption. Any violation of
Section 7071.5 by Any applicant for a permit subjects the RPPIhmI to A civil Penalty of
3y�DNWdl er. 0 0 Occupancy Type _
not mom than 0w hundred dollars (S=L
❑ 1, u owner orthe property, or my employees with wages a their min mmpenudon,
will do the weak, and the structure r. not intended oreffcmd ferade(Sm. 70md,Budrxtss
— RE�y [j}j ERGY
And Prounsions Cock: The Oenusder's License Law does rot apply to an owner or
506 — GAS TE S T
property who Wildsmlmprows the.., and who doeumhwork himselfor through his
own employee, Provided thetsmh lmprovemmu art not Intended mo(feted farssle. If.
507 — FINAL PLUMBING
however, the building or Impnevcment i, gold within one year of completon, the owncP
builder will hove the burden of pmAng that he did not build or Improve for purpose of
tile.).
❑ 1, a owner of the property am anclulwly contracting with licensed contractors to
comuuet the mejec (Sec. 7044. Business and Profnadona Code:) The Conva cu's U.
cave Law dean not apply no an coma of property who builds or Improve, themon. And.
who contracts for uch projects with a conlnetor(s) llcenud pursuant to the Contractor',
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License law.
D lare.Moilunder See. ,BkPCrorthisocmn
µ,pr Data
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WORKER'S COMPENSATION DECLARATION
I hereby afron under penalty or PeDury One of the following daludom:
I have end will maintain a CenlOcau ofComent to selhm,um forWorkce Cmnpcn
cation, u provided for by Section 3700 of the Labor Code, fm the performance of the
weak for which this permit h issued.
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w and will mainum worteB Compensation Insurance, u rtqulrtd by Section
3700 of NC labor Cod., for the performance of hha werk for which this permit is Issued,
,
My Worker's Compensation Insurance carder and Policy number
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GMer./f+'�E '/[Git�- POIIry No.: _`q
CERTIFICATE OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE
Ohis sedion need not ho mmplcwd lithe permit is Return hundred dollars ($100)
- "-
_ or lc.)
I certify that In the performance of the work for which this permit is issued, I shill na
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employ any person in my meaner so an to became subject to the Workers' Compematlon
Laws of California. Dale
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Applicant
NOTICE TO APPLICANT: If, after making Nie Certificate of Exemption, You should
become subject to the Woher's Cempeanitmn Provisions of the Labor Code, you mum
r forthwith comply with such Provisions or this permll shall W deemed revoked.
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CONSTRUCTION LENDING AGENCY
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I hereby drum that lhart its combection lending agency for the performance of
> the work for which this permit r. Insured (Sec. 3097, Civ, C.)
Lender's Nurse
Lender', Address
I sonify that I burs read this pplication and role that the above infomldlun Is
c."I. I agree he comply with all city and county ordinances and mute levo minting to
j building construction. and hemby mthoria rtposlut- tiM of thiaoity to enter upon Be
or Inspection
A ehovo-mentionedProperly fAnd
3. (We) agree to urs, indemnify and kap broadens the City of Cupertino against
exposes whpurposes. a
�y Ilebllitu.judgmenu,nom and expenses which may in my wysmue Against old City
dgm
Z In consequence or the granting of this PermlL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
I$SUed by: Date'
SOUR EREGULAT ON9
00 lV y< �,7 . o.2 0 3
Re -roofs
Type Of Roof
Signs= of ApplianvCen rmtor I Dam
HAZARDOUS MATERIALS DISCLOSURE
WIII theapplicmllarfuture building occupant sure or handle facum us maudal
As defined by the Cupertino Municipal Code. Chapter 9.13, and da Hued and Safety
e, Section 35531(.)7 ^�.
Dyes "
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building Occupant tie equipment or devices which
t brLMem dr contaminants u dented by the Bay Aro Air Qudity Management
all new materials for inspection.
ID[suict?
❑Yes �HTIhavcreet
densma rialsr quiand rats under Charter .95
theharardhus
a33And 2u uedcr
ofdm CalifonHca Ihav
Sread Codheto Srurdocu 25505, derPudthat
ifJu buildings
not cu=ntly hew • tonm4 that It i, mY responalAilOy to mufy tc occupant of dw
Date
ntstvidIt met P�do1'rlllle,umceofaCCN.�R-caby�r"oi:tcSignature
of Applicant
l�L -
All roof coverings to be Class "B" or better
(owner or authorized agent d r—