02100170 (2) CITY OF CUPER17N0
BUILDING DIVISION PERMIT CONTRACTORJNFORMATION
Ru111DM94RESE ESTATES DR JUST WATER HEATERS INCA ..,.. PT:RMITN92100170
owAMAMETSAI 1764 NATIONAL AVE APPLICATI!)nSp"TY2002
ItONE: (510) 293-9901 SANITARY NO./ / CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O�Op LIC ENSU DCONIRACoORS,Frovismorof Cha,
¢u F 1 hereby affirm that I am license)rndef Provisions of Chapter Y(commencing (100
�« wuhSection 7oXXgofDivision 3of the Business and Professions Code.and mylicense is REPLACE WATER Ff
inwItforceandeffect. (40 GALLON)
Oq License Class Lie,X
Z- Dam Contractor
l'= w ARCHITECTS DECLARATION
C I understand my plans shall M used as public mcnNs
KOyU
w 3 w Licensed Pnricsainnal
=in 0g OWNER-BUILDER DECLARATION
<P 1 hereby affirm that I am exempt from the Cunlrsanr's License Law for the
in O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
w$ which m,mors a(permit to ori die,improve,demolish,nr mpmr any somexre $949
Fiy
Prior It)its issuance.also requires the applicant for such permiuo file a signed statement
E
< that he is licensedpursuannnlheprevisionsofineContrazhvSLicens,Law(Chapter9 Sq. Ft. Floor Area Valuation
�s-O (cat he is xempt therefon rom and of hasisnn 3for m the Business edxe prion.nd Any vis Code)(it
y $ that Section
is exempt zany applicator
li and the basis for be allege)applicant
to Any lineation of 3 6922012 . 00
not mo ID3L5 by aundredel (S50rmil subjects the applianl to.civil penally of APN Number Occupancy T
not mammae fivehmnamety.may employees
502 - FINAL PLUMBI G ENERGY P y y�
❑I,ss owrmr of the pmpeny,many employees with wages their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70aq Business 8AS
{�1�Q�[�T,�
and Professions Code:The Contractor's License Law does not apply to an owner of 507 - F I NAL 1/)x);3'1 IVCs ections
properly who Imitator improves memon,and whodl such work himselror through his
awn employees,provided that such improvements arc not intended oroRemd for sale.If,
however,the building or improvement is sold within one year of completion,me owner-
builder will hart[be burden of proving that W did not build or improve for puryose of
sale.).
❑ 1.as owner of the See 7(y,am Business
contracting with:)The Cnmlfanars m
vers,
construct the es not (Sec.'Ilan,Business and rry who
ds or
The ver memor's nd
cense law docs not apply je an owner of pmpcny who seflat or ant to
thereon,and.
whocontractsLa for such projects with a ctmtranor(x)liccnx0 pursuant m me Conuactor's
License Law.
O l am exempt under Sec. ,B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION O
1 hereby arfimt under Penally of pe jury one of the following declarations:
1 have and will main.in
cerfifiente of Cement"I self insum for Worker's Crunch-
union,as provided for by Section 37(X)of the IsMr Code,for The performance of the
work for which this rami,is issued.
❑1 have and will maimain Worker's Compensation Insurance,as required by Section
3701 of the"We Code,for the Perform..of the work for which mit petmil is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy Nn.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nor W completed if the permit is fortune hundred dollars al(f)
or les")
1 worry mat in the performance of me work for which mit Permit is issued,1 shall not
employ any person in any manner w as In become subject to the Worked Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject m the Worker's Compensation prioloons of the"hot Code,you mus,
0z fonhwi to comply with suc In provisionsnr this permits hall W deemed revoked.
'z..' CONSTRUCTION LENDING AGENCY
F Ihemhy affirm deal there is a construction lendi ng agency for the perkomance of
0.a a the work for which his permit is issued(See 3097,Civ.C.)
R] Q Lender's Name
G I<nticr's Address
D
U O I certify that 1 have mad thisapplication
and coup arra state ces the shove information relatinn is
0 U buacn,I agree m comply with all city and county ordinances eed slate laws relating to
OU abed-melding ntiound end hereby authtin Prposexnrmives of thiscity tocnter upon me
alwvc-mcmidgm Propertyst for cafes ion purposes.
F y (We)agree m save,indemnify and keep harmless the City of Cupertino against
fiabily inconsequence
onses.quenc of the gralaindof this cswhich may in any way aa'mc against said Cny
U z A PLIC NT UNDERSTANDS
S nm permll. Issued by: Date
'-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS. (Id
Signature of ApplicaADare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will meapplicantnr future building e,Chapter
sonenr handle Health and
as OcfincJ by the Cupertino Municipal Code,ChapMr 9.12,and the Health and Safety
,daLCotht.Section 25532(.)?
❑ret 0N All roofs shall be inspected prior to any roofing material being installed.
Will the.applicant or luture building occupant use a If a roof is installed without first obtaining an inspection, I agree to remove
PP b e equipment Qu,m devices which g
ist ict? us nit vonWmiwnts as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
P
❑Yea ON.
1 have read the hwuNous mawrialvequirement under ChapMr 6.95 of the Cxlifar-
mallcalth&Safely Ccw .Scedons25N15.25533am1255YL1 undeosmM W,ifwc Wilding
docs no,erotically ham a tenant,that it is my res ornibiloy he army me occupant of the
xquiretecrox which must or me,prior In issuance of a CcmrlcaW ol Oxcrparcy. Signature of Applicant Date
Owner orautWri'mdagent Date All roof coverings to be Class"B" or better