01080128 (2) CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11145 LA PALOMA DR WATER HEATERS ONLY 01080128
OWNER'S NAME: APPLICATION SUB DATE
Ask STETLER BEULAH A 970 E. MAIN ST, SUITE 20008/27/2001
( PHONE: SANITARY NO. CONTROL NO.
(415) 566-2209
nO O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
z w p BLDG ELECT PLUMB MECH
y<i r_I 1=7 1_J I—U
LICENSED CONTRACTOR'S DECLARATION
5 I harcn fOmt that 1 am licensed under 1 Chapter (commencing Job Description
y a provisions o p g
wt-; wiinfoll o homes clerical. iun3.(sM1eStrsinessandProkuionsC.Je,nndmylicrnae REPLACE 40G GAS WATER HEATER
1 in full lone.nJ eRect.
O V License Cl... Lic.M
Dam Contractor
LLQ ri, ARCHITECT'S DECLARATION
,g 1 understand mY plans shell be used as Public records
eTe
t rc p O Licensed Professional
K S OWNER-BUILDER DECLARATION
co-, I hemhy M.that I am sempl from the Conlc¢tor'a License Law for the
I-z< following revs..(Saban 7031.5.Business and Pmfasinw Cade:Any city or county $700
2=A which rtd
qus a permit to construes,alum,improve,demolish.m.,air any"ruatrrt
a 3.sopa s t uanca.ls.rtq res the applicam(ors.eh perndu.file.aigrsidnwetrcno __ _ ._... -- ...__. .. _
that hp i I c mkJ puna m so Ue pmviemns of the Contractors License Law(Chapter 9 s �} F,['{req p�{� ValLLBC10R
(commencing with Sect1nt7000) f Division 3 of the Reforms;and!Professions Cade) C5 .`S j [-3§,p CJ t7.�',pr:,p,V:1�i ti. 1 tial rev
or that he is exempt mcre(rmn'and the basis fm the alleged aiimpdnn.Any violation
-of Swoon 7071:3 by any applicant fora peemit aubjern the eDPlicvm m.civil penalty'
fnot mom than five hundred dollars ls50Bl. 502'sPNNl2g*AL PLUMBIN IENERGYOccupancyType
❑1,as owner of the property,or my employees with svgs us their sole compensation, i
will'd.the Is k,-..d'the'snotoom is.m'tnteaded oI.Bemd ibraale(Sm 9044; ❑t Cf
t Business and Professions Code.The Contractor.License Law dms not apply m an 507 — FINAL P$ 8$ItNCtspectidns n''I`
caner of property Who builds or impmvs thereon,and who dors strain work himself
6 mmugh his own employees.provided thm such improvements art not intended or
�oRcrtd(or axle.IL Bnwaser,the building or improvement is sold within one year.(
marid,tt.athe awn .builder will have me houden of proving that he did not Wild or
improve for purpose of sale.).
owner,.f (Sm.
Businexchusess and atmesngns Cocensedcomnemtsm -�i I p,j;Ie} i�,:.
conswct the jet ISa.)044,Business end Professions Code)I1ie Contractor's
po
Lic La dons not apply to a roamer f property who Wilds improves thereon,
_end ho contracta.f. a ch pmlccts with a cmame oqs)licensed p m to me
Connector's La.,-Le
z ❑Iota pt d,Sa f .ciy t +' HS,PCI thism"in lw:on
Own i.W-RKEERR 1 : Dale TI
WORKER'S COMPENSATION DECLARATION
I hereby dffina mcdcapicanhy of pep ryf the following Jalant ons-
1 foroc iandwill"moot VclamrGiewConsent I;sel6nsura for Worker's
❑p. p arm ,-pr dad-too by Section 3700 of the Lubar Code, for the
pcnbrmunce of Ibe work ror,which this permit is issul.ed. „ -
❑I have antl w ll'm4im IA WorAas Compe sato linunnce.as acquired by Section
i.
371MI of the Lvbor'Code:for the pertom"nm of the soh far which this pennit,is
issued.My Worm,i Comfit his...ree'cvnimund Policynumna wc: "
_ ....'- v..- .._�.�.._.—_._.._._-..
r Ca ,tl � tl2Lt aJYrt'.f olo N r, - f # 4 .... I a ..
". Ir't..CERTIFICATIONOF.E%EMPTIONFROMl''t •'r'1'�'.[ ( tl kl.
COMPENSATION INSURANCE'':!"`-If
LSD-.;, .,site.,..•,, '•r\ :':;ti:i.,.1 y: ._.,._._�.CC:11Yai3:': i-
('This se;if need rwt tic c.mplcfid if the parmit is fns one hundred dollars '
(SIfMI)mleaa.).
It,.I at I
..
_,b Ice.ty thar.the performance ofthe .rkf hirh ilii pemissssiiM.I. _•.....;.r ..-....q,y^• - . , ••,.,, •• ••" .
stall not c pt y anY,IKrs. may s s
C0n w . become wbj n t the Worlen C.C: O :, C:•��:C. C TQ
o pen. I f C hfo
.. Dai.. ... .,.
' "NOTICEp7 OAPPLICA Ifa(ter ma king tan Cmificvm nfC cmpr yushould� ". - �t
OOtkc me sunlecn m Workers Compe sat p ons of the Liho Cud youmuit
forth sh .ply G'sh hp orN perms shallMdend aked.
pCONSTRUCTION'LENDINC AGENCY' ''-'
W Iharaby'air,'71
thpoibeir isa co t et n l nd n6 abentyforth.
fth �
imem s
,;Ihlk wark for which this fiction is issued(Sm.YA7 Ci,,C)
i
d.
Larder's Address'Y'n -Uoeai i grc .tplyl W.11 c sndco ry ordinances and stoic 1 meiingtV mIn fy that Ilroad dappl cm o dee the,the above f mason is
toldngc .mi"o dh rbyethoniptietatvit, f ihi city to enter upon
Y W odio roPeaproperly rpieer parvo
ell
(
V-�
agree IS and eehmesmCity . ..
......._ _...
Cup<mno agarwt
(A liabilities,judgments,costs and expenses which may in any way accrue against said
City in consequence of'he gaming of this permit.'
_ APP LICAYLUNDERSTANDS'ANDMI. COMPLY WITH'ALL'NOWPOIFf"' Issued by: Date
BOUNCE REGULATIONS.,":',;
Signor ofA""a'nVC nv cos It'L - "." Gave
l S Vit"
Re-roofs
liA2ARDOUS h1A'ALS DISCLOSURE
Will
slue applicant or johns
at. budding occupa t"art or'and"
homed. t Typo Of ROOF.
s OefneJ by the CuN"n M unit" Code Chapte 912 and the Health and Safety
Code Sect on eC' I n i 0. IG r'^ r
t�tntlA#(
d32
Y-1
t '71 „ p tf ❑No XQf1,id,r,.:, 66 _,;_All roofs shall.be_inspectedprior.to.any.roofing material.being.installed. _
1l W u me pnpbcs. t fee.-
rop wi ld upant no.c"opm nt tdav¢as which If a roof is installed'Without first obtaining ali''inspection('Ilagreeito remove
arm,h b s comm ata dined by the Bay Arta AvO slay Management
n stn t - r i I _ all new materials for inspectioa_Applicant understands_apd will comply with
sir l.y '(' all ROn-pOIDI SOR[CC regUlah ORS.t'. •,,•., ri'`h.'t.'in1 , T .
I he d'rc.dcihe hvaard...iii no,regmrcmend,uhder Chaplet 695'of the
Califimie Heehh'&Safety Cdda'Saide. 25505.8377 end 25534.1 broack. Nat
ifttienoia'ardmenot cusremtyhmxatenons,that it Sismyd n 31ibilitj to notify me
dceupans of tfi ray iremem )itch- use be met pr or m iuuowe o(e Ccmficvm of " "
,is
O asp oar a , b Signature of Applicant
r � - Date _
Ower, ram nced.goatli D>.e' All roof coverings to be Cass "B"or better
r
I. .= a 7w _ OFFICE -.. ... .. .. ._.__ .._ _ _ . . .
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