02070134 (2) CITY OF CUPERTINO
BUDDING DIVISION PERIVIIT CONTRACTQR''INFORMATION:. '
_ .:.o.,• aa.
BUIMNG ADDRESS: PERMIT
21805 HYANNISPORT DR HOT WATER INC "82070134
_ o RI I ELWELL H AND JUNE 2531 GRACELAND AVE APPLICATO�s� 72002
�PHONE: (650) 298-8494 SANITARY NO. CONTROL NO.
0,-.- ARCHITECGENGINEER: BUILDING PERMIT INFO
s lui BLDG ELECT PLUMB MECH
u
m 2 LICENSED CONTRACTOR'S DECLARATION p
— Iharebyaffimtthatlamlicensedunder,ort,s,onsofChaM,,9(commencing REPLACE WATER H�k Ti tion
win Sections 7000).!Division J.f the Basins.and Pmlessions Code.end my license
in full fort,and Kat.
len 6 Licenu Clssx Lic.N �G
:CRU Dae mr
u O t' -/ nd—/ARCHI 'SS DEC DECLARA ON -
1 understand my plans shall M used as public records
dp O Licensed Professional
o� OWNER-BUILDER DECLARATION
I hereby aRl.that 1 am exempt from the Contractor's License Law for the
$500
C?< following reason.(Season](171.3,Business and Professions Code:Any city or rounry
IF❑ whochotsu«wnce,elm sePermit to uorttheanthem,improve
mans to file alkh.or repair
signed
iranysw«uu
C _
n i !q9., s-.app'a pe signed mumem
(commenaing uwith
pSe«atii.nntl:]o N0e)ofDivision 3thoef the Business
Land
nPuroffaewssions Code)
..- - 13\.�a0. Lr•. t.•.11:s . LzA k\. . Valuation
or Shot he ii 31.5 bi any applicant
ppli and the basis!.r the allegro applicant
to
.Any viol;ion
-of Section than venYdreddllfor$pemetmM1jmstheapplicanttoacivilpcnelry-
'.rtat,n.ee Nen roe n.narca emlera tssom. 502APNIFOURE PLUMBING ENEHGYOccupancy Type
ill,as owner of[he pmMny,or my employees with wages as their sole compensation, 506 - GAS TEST
".ill Bo the work,and the itmctul'is not intended.1.!rend for--sole'(Sec:']Ma;' bU - $peCIlODS
Business and Professions Code:The Contmaor's License Law das not apply to an - -
owner of property Who builds or improves thereon,and who dos such work himself
or through his own employees.provided Nat such improvements are not intended or _ _
.!Terre for ule.If,however,the building or improvement n wld within oa year of --' -" , : Its
-
•cmproveoo,ttopose of an
will have the burden of proving that he aid nm builds '-'
improve four,uryose of sale.)
❑L as owner tepmjhe p(Sec.7,am excBusiness
Professions
ns Codenv h e.nonmoto to
-' wt-,0A
construct s e the proses IS¢, to a,Bus eros and property
who b Code)The improves
thereon, ^ntv�',®.,, ,I
' License Low dos not apply t.an owner of propcny who builds or nmproves Hereon
...and.who.canwcu.fareuch projats with..contmctons)bcenseld.punuant to the _.. ___..__.__ _.... __....__. .. _ _..
01.,Claimable.License law,.
gU0 1 2 2002 -- — :
❑lam exempt une<rgee. " ' '' ,B&P C for this reason
net : OSIS TION LA ,;: BUILDI1VCa
WORKER'S COMPENSATION DECLARATION
L �^ Ihertby.farm undo penalty of perjury one or the fallowing decleretimen,
❑ I fm6c eod'wiif aoilmht&mriuute'a Consent to lel!-Invite for Worker's "
'. Compensation, as-provided"'for-bySection 37M of the Labor Code, for the
perfoimedce of Ne work for which this pertain is iuvea. '
eve and will examu in worker s Comp nuiion Insunnce,as mquiue by Sectidn
W of the labor Cada for Ne per(oimann of"Ne work f r' mch this
!is
towed MY W kee Compe n lnso once certi W policymbcr a w• _
Cemaa`�ol ey No.. t t••...f',•5 Ir , 5 r.f.-, ro i t „U:;••, ___..
!rt RTIFICATION OF EXEMPTION FROM WORKERS' s a 1, j•"• - 1
- r
T'1' t P' 0r ; COMPENSATION.INSVRANCE _
"'' (Thte senibnn Nnothcompleied ache permit is(a one hundmd dollen "' - "'
r;r 1 actors,N;'in the pedurma ns of th' work ro which a ptosed s staled I
shell dot min Laws
perwn to any man«w vs m become subject m Ne Walloons. I.°-s' '' I `• 't`
p
C.
mp:itel.ion laws of CaliforniaI Date"
...v.I d I.__
'NOTICE TO APPLICANT.1l,eftcr making thisCmiOcae.f Exemption.you should 5' -":,= '.t ,?•.".'.. '.'t
O Obecome sups&i to the Workers Compensation provisions of the Labor Code,you mut
Forthwith comply ,th aOCh pfov 51«05 Or Ih s parm 6haII bt dttmea RV.kad _ -, ., - __ ..-.•- _ I - - -,�,._.. ..
zzs"777 "" " CONSTRUCTION LENDING AGENCY
fFl, � Le IhercbyaRirm that the Is enstiunt nl'ndin eg yfor the perfoiinea 'st �
,. p
� Ne wo k for hlch the permit is sued(Sec J09] Civ C)
U 0 „1 cmify Net 1 have teed this epplicetion end atm Nenhe above
at!..is -
Ra"E.t io.ecs.1 ague tp comply with ell city dntl.coumy ofeinencea end state laws rcliums
O,'U to building mnmm�ion:ane heuby emhonie represenalives of this eitymenia,.,n
�.1s W' the above-mentioned property for mspenion purpows _
L'. P+ IWe)egrtt io wee;indernnify.ead keep harmless the Cn`y of C'upenino ,.last
{Frr'tn liabilities.judgmenu,costs aM expenses which tory in my way accme again;aid
U City in can;uence of the rantiof Nls ermit "
SOURtCeA , IW . , INT
KEG Issued by: Date
Signatdrtbf ApplicontMonvactbr'":";a ....t_,,.. _. -v•..,Dau"";,
+ - HAl xBOGUS MATERIAL$DISCLOSURE s 1 Re-roofs
eppll®nt or f mu building occupant store or handl hazndous met ml Type of Roof.
laid
,found byN nin C peMoollip.lColl Chvpser912ana On Health road Safety
-'
Ccoal sell..83J34)7s I I I
i) I •" � 'If f ♦.'
... .
r 1. ..... All roofs shall.be inspected prior to,any_roofing matenal.being installed. _,._.__.._
Willtbeappl ca to fu budding anpe tsea cqu:pment or devicee.wh ch If a roof is insialled without first obtaining an inspectlol;T agree.t6remove
ermt horsed. ontaminann ei defined by the Bsy Arta A r Quality Management
Dtamct
_ all new materials for inspection Applicant understands_and will comply with
r „ roe«Ib t a y 1 ,, all non-point source regulations
I have ond:Ne he as materiels gwrcmenti under Chapter 6.95 of Ne
Cel l.mte H alth k Safer ode Secu as 35505;35533 and 25534.-1 undcntim that
tLih stole ng ads ante Wendy ha eetenem that tis my responsibility nobly the 9 LIC ,
occupant of the uquimmetns htch mail be'm<t poor to Issue ce f e CeuiO«te
Occupancy : . .P
�7 C Signature Of Applicant. . Date
- -'
opt
on¢ea agent Data All roof coverings to be Class "B"or,better '
` -b- - 'OFFICE_ . ._._._ .._. __. - _. . -- -