00120114 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILD INC,ADDRESS: PERMIT NO.
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WATFR HFATERS ONLY 14,t0120114
OWNER'S NAMH APPLICATION SUB DATE
Omn 51T . IRT BLV 12/18/2000
id IONF. • •• n_
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SAKI1'ARY NO, CONTROL NO,
1 1 i49—%747
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ARCHITECT/LNGISELR
c,0 . BUILDING PERMIT INFO
w _ BLDG ELECT PLUMB MECH
FQ,d UJ CI 1=1
z -Cr;Nsl11)CONTRACTOR'S DECLARATION
�z=o Iherebvalrrmmnlramreen,eaunaerpm„.inn�nfcname,vmnmmeneing Job Description
Fyk;;c with Section7j0(B of 1)ivicirni3a1'he Bunincs and Prof—ion,Code.amin,ore c
6 ^-) isin full finers and effia.
C O at U License Close Lic.p
3 a y Dara Contractor
17 tea ARCHITEcrsDECLARAT]ON WATER HEATER REPLACEMENT
1 understand my plums shall he,used as ohlic records
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y
d o O Lic,nsed Profnsiunvl
oPs OWNER-BUILDER DECLARATION
u h—� 1 hereby Imran shah I am c,cfnu tram the Contractor',1 icen,Law for the
followingreawn.ISavion 70315.Businessand Profeaiom Code Any cityorpmnty -
zF o which acquires a I,n th is conewci,alter,improve,demolish or repair any swcmre
alt- prior to its issuance.also requires theapplicani for such pam,il to life a signed smtememt
that he i,licenwd lnasom,it)me provision of the Contmcmrs License Law(Chapter y S Ft. Floor Area
(commencing x iih Section 7l(yBof Division 3 ofne Business and Pral'nslmn Code) u' Valuation
,it that be iv r o to lherctnna and the h,,i,Im it,,alleged exensption.Any violation
of Section 703 LS by any upplicanl for a It.subjects the applicant ton civil penalty
of m1 more than life hundred dollar,IS5001. APN Number Occupanpe
C 1,a,owner of Nie pnpsrt,or my,aa,loyeo,with wages.,their,ole comPcnmtion.
will Ars the so rk.and the ownum is Bol intended or offered far,ale(Sac.70il
Baine,and 111 ..aa Code:'Ilie Coidr,em,,Licea.e Law dobe,not apply ro an 32E481Z11,=,. i�ikl9uired Inspections
oxner of pro,.,Who haild,or improve,Bacteria,ani wan docs welt work hinneIf
oa nhronpl,his own randoyee's.provided shot,Lich imprnvemmtuare nal intended or
ffered for sale.IL however,the building or improvement i,soli within rine year of .
im...pladnn.meowm'r-bnuduhwillhatetoehandotafp,...m ,It.,oedidnotnwldor 502 — FINAL PLUMPING ENERGY
prove ror p aWse of aIle.).
C1 1.as owner of the property,am cxvlu,ikcly contracting with licensed contractor,to 506 — GAS- TEST
woarp IIS 7wsB : a, n I :',m( aCon tmelra 507 — FINAL PLUMBIN
License Law d t anal perry h,hand or
improve;I n
. -
d M1 t 1. farorfelt , witht , nq dm a tire .
Contractor,Lbon. La..
-
olamt,s ruk,S ,It&P Cl iia'co,
Owner Dam -
WORKER'SCOMPENSATIONDECLARATION
1 hereby atlinn Indra penalty of perjury one of he lullnwing dcelarations:
J I have and will maintain a Cenilica,e ml Consent to alf-inure for Worker, //!l
Cnhnpcn:nion, ns provided for by Section 37100 of the Labor Cdr, for the l/
mnftnum nee of the work for which this Permit is issued
C 1 have and will trontain worker',Compensation Insurance,a,required by Section
390()of the Latour Crdr,for the perforhnunce of the work for which this permit is
issued,My Worker's Gnnpenschon Insurance carrier and Policy number art,. ;
Carrier: Poll,No.:
CERTIFICATION Oh EXEM"ION FROM WORKERS' '
COMPENSATION INSURANCE '
IT -action maid no,W camjo Ned if am permit is for Inc hundred 6.111 m
IS KAU or leu.) -
1 cenify that in the perti,mmnce of the work for which this ivrout i.issued.I
,hull not employ any person In any taunter no as to became subject to the Workers' -
Comprnsatinn Icui of California.Dane '
Applicant
NO['ICF,'rO APPLICAN'n If,after making this Certificate of IixanptAn,you should
hetrmne anhjen m,M1e Wodor'c Cnntlx7taminn Pnrvininn,of
the I,aho,Gde,you mus,
Q
Z O li,nhwilh comply with such previsions or this Permit shall W deemed revoked.
r
FCONSTRUE construction
agency
1 rkto,altbth Th.Ldo,reran i is
mued(Sec. lending vgu,tev ror the ptrli,nnuncc
of a e r s N for x hich Nig permit is issued(Sec.3847.Civ.C.)
z
Leaders
z Lender's AJJtess
U 1 cenify that I have read this application and„ate that far adn'c information is
V. hcorrect.I agru„a connply wish Ill city and connny ord muton and state law,rel Wing s
C) U R,building construction.and hereby uuthorim tepm%en,ative,of this city to enter instant -
} W the above treat ioncd property for impcc,inhh purposcn.
ra. (WO agree to soar,indemnify and keep hamre,,the City of Cupertino against
Vi liabilities,jndpnores.coats art ev,:n,es which miry in:my way,came against suit
City in consequence of the granting of this permit.
h� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.PUIN'r Issued by: Date
SOURCE REGULATIONS.
Shgmnarcal Appheant/Commcmr Dare Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE
Will iheapplicmn or furore Wbdm,c,,a,i store nr handle hatad,ws interim Type of Roof
us defined by the Cri,mon Municipd Cost,,Comte+4.12,and the Hminb and Snomy
Gate.Section 23532(,):'
°Ve, 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future he(ding hmcupam nem niu or at or devices which If a roof is installed without first obtaining an ins ection, I agree to remove
i,huaunluus dor contaminants to didined by the Bay Area Air Quality Management P
trie'tyall new materials for inspection. Applicant understands and will comply with
6Yc, CNo all non-point source regulations. PP
1 I onto read the Imzanlou.s materiels fcquiremcms under Chapter 645 of the
Cali humin Health&Stacy Code,See on,25505,25533 and 25534.I understand that
if the handl ng does nue currently have a tenant.that it is my respntsibil ply to notify ted
occop,m of Bhe requirements which mu,r be me,prior to issuance of a Cenpirate of .
Occupancy.
Signature of Applicant Date
Owncrnrantnmi,edagem Dae All roof coverings to be Class `B”or better
OFFICE