03010181 (2) CITY OF CUPEWI'INO 3y .'Oaam..;.,tira +
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
BU I LDING ADDRESSHOT WATER INC PERMIT NO.
21607 FLINTSHIRE ST
NER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
JEFF JIAO 01/28/2003
'ONE: (650) 298-8494 SANI TARY NO. CONTROL NO.
ARCI IITEC/ENG INEER: BUILDING PERMIT INPO
BLDG ELECT PLUMB MECH
0 0 o
I°^u 00 LICENSED CONTRACTOR'SDE,imoof bar
z
OZ F 1 harcby storm mal I um If ire Bd under previsions of Chapter 9 mylicensi is Job Description
Gawith Section]IXXBnf Division 3nf NC Bua ssand Pusfccinns Cook,and myliccnscis
roti infOlIR andeffe 3� 75� REPLACE WATER HEATER
oZ&I? Dam( s Lia Xo for t
F''-A'-w 1 CHITECT'CLARATION �I���E®
�Yiyy� �dctsetud myptans shall he used as public words
txn 3 dial-, Licensed Pmtcssinnal
MAR 0 3 2003
L'°' OWNER-RUILDER DECLARATION
e, a Y I hcrcby.scei urt I am exempt from the Contractor's,o License Law cu and BUILDING
ii o O following masom affirm
to t I Con.Business and he Contrac oz's L Any city or county
x$ which requires a pctmi,m consume,,alter,improve,demolish,or repair any stmeture
1O—'^ that he incensed pursuanto fire provisions
visio so for Conrmminoicense aw(Chtomcn, �t,.a.ra
CSO mutbelshennawd Sectio7kXh of Division 3 theContractorsBusiness nd Professions
Code)or Sq. Ft. Floor Area $ykkatgrtlOn
¢� dor he is exeming pt
Sectian7land Of,basisnfr tof he alleged
and Professions Coda or
i 3� Nat be is catmp,therefrom and Ne basis for the alleged exemptimn.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant n a civil penalty ofe Occupancy Type
not more than five hundred dollars(S501).
❑1,re,owner of the pmperty,or my employees with wages res their sole compensation,
will do the work,and The wr clus,is not intended or offered for sale(Sec.71166,Business
and Professions Code:The Conlmcmr's License Law docs not apply to an owner of Ulre nspec Ions
property who boildsor improves thereon,and who docs such work himselforthmugh his 506 - GAS TE
Own employees.provided that such improvements are not intended ofoffered for adc.If. 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion.the Owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ h as owner Of the property,am exclusively contracting with licensed contractors to
conawcl the project(See 7014,Business and Professions Code:)The Conmacum's Li
ethic law does not apply to an owner of property who builds or improves thereon,and
who cone tui for such projects with a commercials)licensed pursuant to the Contractors
License Law.
❑ I am exempt under See. ,B A P C for mis rcrwn
sooner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declarations:
I have and will maintain a Cori foam of Consenno self-in pen-
sure for Performance
s Cum
scion,r provided for by Ss issued.37th Of the labor Code,for me performance of the
work for which mis permit is issued.
❑ I have and will maintain Worker's Cumpcnsaion[radiance,az required by Section
37tX1 me labor Cede.for the performance ofthe work frrwhich this permit isisested.
My y</rk '—rydp naauon lnsurinwirrier and Policy�mbe
varier:.�S[�„//
CER'1'IPICO OEEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mos section recd nm be completed if the perms,is foronc hundred dollars o)(a))
baoij
I certify that in the perinm,ance rel the work frr which This permit is issued,1 shall not
employ any person in any manner m re to become subject o the Workers Compcnsalion
Lawsof California.Date
Applicant
NOl'ICE TO APPLICANT:If,atter maki nB this Cc nillcatd of Exem pion,you should
kCOme subject to,he Worker's Compensation previsions of the labor Code,you must
O z forthwith comply with such provisions or this permit shall be deemed revoked.
azr"O TI
CONS LENDING AGENCY
[-+ I hereby affirm that there is a cmn9lme,ion lending agency l Or the performance of
a ,hework for which This permit is issued(See.3097,Civ.C.)
lg1 Lender's Name
6.
z Lender's Address
U
TJ Q I certify that 1 have read this y and c un and sum that the above information relating
is
0 U condor 1 agree ctcomply with all city ri county ordinances and sty t lows relating e
OCJ imonnmentiommionand forebyaumonp rposesenutivdsml this cirywenter upon the
r D, aMwe-me judgments,
property for expenses%hick may
a
pa (we)agree to save,indemnify and keep harndess the Ci iy Of Cupertino against
UZ in Consequence
Of the costs and of this Psmit. mayinanywaydecree against said City
V z A consequence UNDERSTANDS
ut this Permit.
APPLICANT UNDERSTANpS AND WILL COMPLY WITH ALL NO -PO NT Issued by: Date
SOU ;GULATIONS.
Re-roofs
alum mf ApphcanVConuanm Da o
HAZARDOUS MATER[ALS DISCLOSURE Type of Roof
Will the applicant or future building occupant xmre or handle haoardous mawrial
as defined by the Cupdnin,Municipal Code.Chapter 9.12.and me Health and Safely
,dJILCodc.Scclinn 25532(a)'7 [�
❑area �IN„ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future heading Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
i,hazardous air contaminants as defined by the Bay Arca Air Utility Management all new materials for inspection.
istricn
❑Yes �Nn
I have read me hazardous materials requirements under Chapter fi.95 of the G,lil'rr-
hixllcalm&Safety Code.sections 255)5.25533 and 25536.1 undersand tha,it de Wildi g
does no haze a wnanL mat i,is my responsibility w notify me utc.p I Of
req entewb bmux,hemelPoortoeammceofacerifieae,aacupancy. Signature of Applicant Date
Ow/ hhri,ed own, „e�03 All roof coverings to be Class "B" or better