03010036 (2) c►Tv of CUPERTINO
CONTRAC�°TORbIN ORMATIBUILDINGNC DIVISIONSION
BUILDING PERMIT
BUILDING ADDRPSSt WATER HEATERS ONLY ` PERMITNO.
10300 FARALLONE DR 03010036
OWNER'S NAME: 970 E . MAIN ST, SUITE 200 APPLICATION SUB DATE
GOLDMAN MARK S AND EILEEN R rR 01/07/2003
ItZONE F4-1-5—F5 6—6—2 2 0 9 SANITARY NO, CONTROL NO.
ARCHITECTIENGINLER: BUILDING PERMIT INFO
BLDG ELECT'
00 PLUMB MPLH
0 E 0 0
One,
LICENSED CONTRACTOR'S DECLARATION
s u t- 1 hemby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
Hw withSection 70O(dofDivisi 3ofthe Business and PmdssionsCale,add mylicense is 1Y �w
��? infpllhl¢c and c 45 REPLACE WATER HEATER. �AL.g
Lirensc Class Lic.N
spy_ Dam Contractor
F-1—w ARCHITECTS DELLA A ION
I understand my planxshall W used as public records JAN .2,,$ 200-
se au .
at
B u.t, Licensed Professional
F.LLypj OWNER-BUILDER DECLARATION
Cie a q 1 hereby affirm that 1 am exempt from the Connector's License Law fur the BUILDING
a o:n 00y following mi um.(Section]1131.5.Business and Professions Code:Any city of county
_
ad LL which m9uircs a permit to construct,alter,improve,demolish,or repair any structure
Iy Poormits issuance.also requires lhexpplicanl for such pconumfleaeignal summem
s O that he ivlicensed pursuant to the provisionsortheContractors Live"Law(Chapter 9 Sq. Ft. Floor Area $VO&tion
or (commencing with SetLon7000)of Division 3 ofthe Businessand Prema,inns Code)nr
a $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant n a civil penalty of
not mere than hve hundred dollars(s5B0). Occupancy Type
(2 I,as owner of the property,or my employees with wages as their able compensation.
will do the work,and the structure is our intended Or Offered for sale(Sec.7014,Business
and Professions Code:The Commences License Law does nn apply In as owner of 506 — GAS TE uire nspectIODS
pmpemp;oy .priviimpraveatheeeon,andwhodomsuehworkproffeedithaugh Inside11. 507 - FINAL PLUMBING
own employees,D or i But such improvementsarc not intended oroffefed Inside.
builder ..the have building
the
m improvement is hold within or¢year of mproe for the Owner
builder will have Ire burden of proving that he did not Wild a improve for purpose of
sale.).
C I,as owner of me property,am exclusively contracting with licensed contracmcs to
conswct the project(Sec.7114,Business and Professions Code:)The Condiment's Li-
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a mmranof(s)licensed pursuant to Its,Contactor s
License law.
❑I am exempt under Sec. B&P C for this..an
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRrra under penalty of perjury one of the following declarations:
1 ban and will maintain a Cenificatc of Consent n self-insum for Warker'sCompcn-
sation.as provided for by Section 3701 of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
7N)of the Labor Code,for the Performance of me work for which this permit N issued.
My Work im y Insurance care,r and Policy /1n arc:(
2-3
CHRTIFICATIi "REMI'1'ION FROM WORKERS'
COMPENSATION INSURANCE
or is section need not Mcompleled if the permit is(or one hundred dollars Pita))
less.)mus
1 cenify that in the perfnrmanae of the work for which this permit is issued.I shall not
employ any person in any manner an as m become subject to the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccni lieme of Exemption,you should
Mcomc subject to the Workers Compensation provisions of the Labor Code,you must
O z forlhwi th comply with such provisions or this Permit shall Is,deemed mvoked.
Z O CONSTRUCTION LENDING AGENCY
F I hereby affirm that there is a cunswclion lending agency for the perlormadeco,
a the work fire which this permit is issued(Sec.YN7,Civ.C.)
aW 0 Lender's Name
=z Lender s Address
U 0 I cenify that I have read this application and site that the above information is
it, P correct.I agree tocomply with all city and county ordinances and sum laws relating to
0 U Wilding construction.and hereby authnnm Milesenufives of this city to enter upon tM
,,0 above-ms,Judg Judgments,
property
st for i expenses which may
F y
WC)agree m save,indemnify and keep harmless the City of Cupenimo against
h liabilities,judgments,cosuand expenses which may in any way amore against said City
U Z APPLICANTc NDERr alingTAN of this permit.
'—r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-P INT Issued by: Date
SOURCE REGULATIONS. ,rel // / /
/Jr +e/ ���— D/�3 Re-roofs
Sfgnmurc of ApplfcanVCnnlracnr to
HAZARUO 5 MATERIALS DISCLOSURE Type of Roof
Will me applicant n moon building,ecup inn store inhandle hafandoos mamdal
az defined by the Cupenino Municipal Code.Chapter 9.12.and the Healer and Safety
fide,thin 25532(x)'/
❑rex � All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future buildingoccupxm use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by me Bay Arca Air Quality Management all new materials for inspection.
D
istrict?
❑Yes 'l<-f
03
1 have read the hand1st s materials deramments under Chapmr6.95 of the Califnr
io llcal h&SalctyC de.Sections 25515,25533 and!255M 1 undcrsmnd that ifmc Wilding
ocs not currently have a tenant,that it is my res,tust ility to nold IM t eupanr of me
gwmmen me
pn1 r `mxncenfaCemficaleofafuancyy Signature of Applicant Date
Ofain orinik gent / all All roof coverings to be Class "B" or better