03010117 (2) CITY OF CUPER'I'INO � ��"
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.
10284 CRESTON DR 03010117
WNER'S NAME: 970 E . MAIN ST, SUITE 200 APPLICATION SUB DATE
SORENSEN MARTIN L AND LAURAL E 01/22/2003
orONE. 415) 566-2209 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECI1
p0 LICENSED CONTRACTOR'S DECLARATION O O O
efU F I hereby arum that I am licensed under provisions of Chapter 9(commencing Job Description
�<i with section 7000)of Division 3 of late Business and Profess .Crate.and my license is
mBfnrteanaeg 6 3 ,7=Z3 REPLACE WATER HEATER, FINALE®
F'LIZ License _�Lic.N
p?�p Dam 3( 0 3 Contractor
w ARCH ITECT'S DECLA ATIO MAR 0 7 2003
1 understand my plans Shall be used as public records
XpdO
w30, Licensed Professional
F pj OWNER-BUILDER DECLARATION
u ap I hereby affirm that 1 am exempt from the Cnntractar'n License Law for arc BUILDING
w_00 following reason(Section 703 L5,Business and Professions Code:Any city or unumy
o,w which requires a permit to summoner.after,Impnnc,demolish o
f rePair any structure
poor ur its issuance,also requires the applicant for such launch to file a signed comment
Hca that he is licenced pursuant m the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area $Via ttlon
ad (comamour ng with Section 7000)of Division 3.f the B usiness and Professions Code)or
e. $ that he is exempt thcmf..an and the basis for the alleged exemptinn.Any c...Wind of
Section 703 L5 by any applicant for a permit subjects the applicant to a civil faculty of beO Occupancy Type
not m..than few hundred dam,(S500). p Y Yp
wi Lasowrcrof the pmlkny, re is employees whatwagesastbcir sec,compensation.
will dolhework.andtheIO,Contractors
tended License
offered do forot apply to an Business .1q
.it Professions ld.ori pr Contractors License Law arcs or apply lf an owner of 303 - ROUGH itSDCCrLIOns
Property who builds or improves thereon,and who arcs such work himself or Borough his
Own employees,provided mat such improvements arc not Intended oroffemd for We.It. 304 — ROUGH ELECTRICAL
however,the buildings improvement is sold within one year of completion,the owner-
builder will have the burden of pining that he did not build s improve far parpoe Of 505 — FINAL ELECTRICAL
sal.')' 507 - FINAL PLUMBING
D1,as owner of the Property.am exclusively comeacring with licensed contractors to 508 - FINAL MECHANICAL
consumer the pmlect(Sec.70fA.Business and Peotesxions Code:)The Contraetnr's Li-
nsc law does not apply to an owner of propeny who builds or improves thereon,and
who contracts for such projects with a conmactor(s)licensed pursuant to the Contractor's
License Law.
D l am exempt under Sec. ,B&P C far his reason
at, Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarxtioee:
I have and will maintain a Ceni ftcate of Carbon,to e,lf heart fur Worker's Comped-
.firm as provided for by Section 3700 of Ne Liber Code.for the pe me nauce of the
work for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700.1 the labor Code,fit,the performance of the work for which this .it is issued.
My Worker's Co Nation Ins tics ace carrierand Policy number art:
Carrie, Policy No.:J1Q,)_L30'Z—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rbis.e Ll.nneednotbecompletedifIMpermitis Intonehu.drtd Jolla,o lad
or jum.)
1 canny the in the perfmmance of the work far which his permit is issued.1 shell an,
employ any person in any manner so as bt become Subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ce tifiaate of Exemption,you should
become subject to the Worker's Compensation provisions of the Luba Code,you must
OO forthwith comply with such provisions m this p card.vhal IM deemed revoked,
z N CONSTRUCr10N LENDING AGENCY
(—r Iherehy affirm that there is a cansmenim lending agency tot the performance of
LK the work for which this pc'and is issued(Sec.3097,Civ,CJ
Irl Q Leader,,Nam,
ess
7 Z buildings Ant �.
V Q 1 certify mat 1 have mad this application and sum that the above information is
IyF cored.l agree to comply with all city and county ordinances and stem laws relating to
0 U building construction.tionerend hereby acouni areprescnmtives of this city to enter upon the
F yabove-memWned property for inspection purposes.
(We)agree in eve,indemnify and keep harmless the City of Cupertino against
h
liabilities,iudg of theosts ading of this expenses which may inany way theme against mid City
U Z A APPLICANT
of thegoadingof this permit.
.. APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL N N-POINT Issued by: Date
SOURCE RGGUhAI'10
Re-roofs
Signature of ApplicaDAZARDO Dare
IfAZARDOUS MATERIALSainue.SURE Type of Roo(
Will the applicant or future building e,Chapter
cove.,handle Herith and Safety
as defined by the Cupcnino Municipal CnJc.Chapter 9.12,and the Ilcalth and Safety
7does
Wc,Stan..25532(.)'!
Dr x — All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupier use equipment s devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous aircontaminams as dcfincei by the Bay Arca Air Quality Management all new materials for inspection.
istrict) p
D Yes No
1 have mad the M1mard.us materials requirement under Chapmrh 95 of the Califon
in Halm&Sufcty Calc,S,cm ns 25F15,25533 and 25594,1 understand Not time building
not cuncml A v tenant,that it is my respmsibility to notify the occupant of the
equinemen ichor th,metpno issuance or aCenificateofoccupancy. Signature of Applicant Date
wnefur uamotl,ca tar Date All roof coverings to be Class "B"or better