02100157 (2) CITY OF CUPERTINO ' � Fes-"° AT "`""
BUILDING DIVISION PERMIT NTRACT
COOR INFORMION:-
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BuIgD6480juS1EAVES LEY PL WATER HEATERS ONLY PERMITNO2100157
O`Y9MRZ WALTER JR AND DELOMA J 970 E . MAIN ST, SUITE 200 APPLICATPMsr2D212002
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IIONE: (415) 566-2209 SANITARY NO. CONTROL NO
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op LICENSED CONTRACTOR'S DECLARATION dohT'
I hereby.1 mpt
rm at l am licensed ender provisions of Chae,9(commoneing REPLACE WATER -Wgpllon
with Section VfNxO in Ditkion3 of the Business%end Pmkainn%Cnde,and my license is
in full forceand elyµ�l. 3( •] G '�
Zo Z License la C.: Lie.N 3 .J
OZ— Dale Contractor _
ARCHITECTS DECLARATION PINAL.ED
�Yiy y I understand my plans shall be micros public record,
LLaLicensed proks%iana' MAR 2 5 2003
2H
OW NFAm exempt form the C miumul
a 3<Y 1 hereby uflirm that 1 am exempt from the Cnmranors Liccnsc Law boils, $700
w—"10 following reason.(Section 7031.5,Business and Professions Cade:Any city or county
$4 which requires a permit us construct,alter,improve,demolish,or repair any structure
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pro,to it,issuance,also rryuimsthe applicant for such Formino file a signed sutemem
that he is licensed pursuant to the provisions of the Contractor's License LAW(Chapter Y 3ST. l£t5&7�efr Afi;6 alUatloO
��$ (commencing withSmian 7IXNp of Divisinn7of me Business and Pmfessinns C.Je)m
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject%the applicant to a civil penally of
no,more man eve hundred do0a.(S50o). 506pp NGAS TEST Occupancy Type
❑1,a owner of the property,or my employees with wages As their sok compensation,
will do the work,and the strucm¢is not intended or offered for Sale(Sm.7DAL Business
Add Professions Code:The CmIneud i License law door no,apply to an owner of 7eequ= nSpectlons
property who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements Are not intended oroffered for sale.If.
however.the building o,improvement is sold within one year of completion,on owner-
builder will have the burden of proving that he did no,build or improve for pu,msss of
sale.).
❑ I.as..or of the porport,am exclusively contracting with licensed convenors,.
construct the pmjecl(See.70,14,Business and Professions Cods:)no Contractor's Li- .
cense law docs not apply to an owner of property,who builds or improves,hereon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Cnmmcor",
License Law.
❑ I am exempt under Sec. ,B&P C for oris motion
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following decla emal:
I have and will maintain a Ceniform of Consent to aelf-insure for Workers ComPem
sa,inn.az provided for by Section J]fLam
or of the Iar 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
11 X)of the Labor Cale,for the pmformance of the work for which this permit is issued.
My Workers Cs B�y�y;�^Pias anceca eeand Pmm'.mAOc,.mt/
Cartier. -sem / ��Policy Nm/t24 5723•-O
CERTIFICATE Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcompletcd if the permit is Torun hundred dollars OHXB
nr less.)
I certify that in,he Performance of the work for which this Permit is issued,1 shall not
employ any person in any manner so as to become subjeeuo the Workers'ComPcnsmion
Laws of Cm,fornia.Did
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicate of Exemption,you should
become subject to the Workers Compensation previsions of the ladn Code.you must
OO forthwith comply with such provisions Or Permit shall be decreed revoked.
Z ( CONSTRUCTION LEN DING AGENCY
H I he to by affirm that there is a cnngroc,ion lending agency f or the performance of
(xr7 the work for which this Permit is issued(Sec.30X97,Civ,C.)
0 fender's Name
gla 7 Z fender's Address
f,Q 1 certify that I have read this application and sure that the above information is
W E.,
correct.)Agree to comply with all city and county ordinmma and sure laws rotating to
0 building construction,and hereby authnrim Mintsenmtives of this city to enter Alum the
W ab.o.-Ann ilmod property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Curarlino agal nst
„-t V) liabilities,judgment,,costs and expenses which may in any way scenic against Said City
U in consequence of the granting of this permit
'—' APPLICANT UNDERSTANDS;
ANB ANDSTTI{A�� -POWT Issued by: Date
SOURCE REGULATION /L/
Re-roofs
Signmum of A,pliamrA7,mImcUm Dam .
HAZARDOUSrMATERIALS DISCLOSURE Type of Roof
Will the applicantor future building occupantstoreor handle InOm ous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Crwe.section 25532(a)] - All roofs shall be inspected prior to an roofing material being Installed.
❑Yes 1� P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haamdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
,Oil(
1
❑Yes [I-
1 have read the haraNnus mamrial,myuimmont,antler CAapkr b.g5ofthe Calif.T-
nial{calmsSafc,y Calc.Scedoa259)5,25533.d25534.Iundcrsund Oatifthc building
does not currently hale a tenant that i,is my respoalbili,y to nodly ftWt Pam of me
requirement ct ,he mm pd m_ssuanceof.comficamof�u c, Signature of Applicant Date
Owner m aemod]• seen, „p All roof coverings to be Class "B" or better