00050156 (2) ' MY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING Ay13c066 LINDA VISTA DR ' WATER HEATERS ONLY PERMI'YNO. ---�I :�:o
°WNHR'sNCtILLIER BERNICE B TRUSTEE 500 AIRPORT BLV APPLICKNON SUH DATE
PHONE. SANITARY NO. CO RO N .
O z ARCHIFEC/ENGINEER; BUILDING PERMIT INFO
(415)349-3747 BLDG ELEcrPLUMB MECH
to�1a
F N LICENSED CON'med mda,'s DECLA RAI'IDpt Job Description
�O Zy y o 1 hcrchy oftinn Ihnl 1 um Ilccn.cud under prav Pions of Chapter 9lcmnmencing
wish Section a and
of Division J of the Business arid Professions Cale,and my lic,n.o
ma4 iscefull force and¢Beat.
d m u. License Class Conti
'�3 a.y Uma s DECLAr -
H�p ARCIII'I'IiCI"5 UIi(:Lnkn'mgN
1 understand ory plans shell he umd m public etvNs
.,as REPLACE 40 GALLON WATER HEATER
p Licensed Profnsional
a a o OWNER-BUILDER DECLARATION
t�i m I hereby•pian that I nm,caeinpl trial,the Cnarucmr's L team,Law ha the -
F•>. fullowiny reason.(Section 7031.5,H-ine,and Pmresslnns Calc:Any city or county
EZ which requires a penail to coast•,alter,improve,diabolist.or repair any straame
a3 poor to its issuance,a6o requireshe applicant for such permit to file a signed statement
'hat he is licensed pmsuam to the pnwafons of[tic Commcmis License Law(Chapter 9 Sq. Ft. Floor Area Valuation
mnmmencing with section lam)of Donation 3 ofthe business amt Proc%kions Code) $700
or Itom he ie client),larcfmland the len—far the alleged esmnp,ian.Any viulmlon
of Section 7031.5 by any applicant for a peril object,the applicant 10 a civil penalty p�
of not In.than fan hundred dollars A,3`t;1%&4. 00 Occupancy Type
❑I,as owner of the proper,or my employed with wages as their sole coml,en clam. y�p1
will da the work,and the mean a ix no'intended ser ahead for ole(Sat.7044•
BnsHness and ro,1a,,ian.Ca I,, lbe Cm'mctorx Limenxe Imo due,l,o,nm,Iy 1.an Required Inspections
o.aarof Coope.,Who builds or inpmves thereon,and who docs such work himself
or thmngh his own employees.provided that such improvements are not intended or
offered for sale.IL hawevca the building or improvement is said within one year of
nnpletion,the owner
r Ember will have the burden orproving that he did not hand or _
hnpea,r pugar orale.). 50�Q FINAL PLUMBING ENERGY
01.asowner ofthe pmper,amasauseelya,ntmctingwith licensedcantramnrsto 506 — GAS TEST
consumer the pmj«r(See.mut Business and Professions Code:)'IT,Contractor. 507 — FINAL PLUMBING
License Law does nm apply man owner of property who hullds-or improves thereon.
am I who annraclx or wch pngcas will a...nwaor(s)licensed pnrs,am, ,,the
Cuam ex's License Law.
l
O I ons exempt under Sec. .If k P C for his reason /
Owner Data
WORKER'S CUMPENSA'IIOh'DECLARATION r�
I hereby allirn,under penalty nfpe,na,one of the following Jeelarvtlonc10 /
1ha%e and will maintain a Certificate of Consent ,,self-insure our Worker's
Cninpcnsa'ian, as provided far by Section 37M of the Lada Code, for the
performance of de work for which this perit is Issued.
01 have and will maintain Worker's Compensation Insurance,an required by Section
3701)of me L bar Cade,Ca he performance of the work for which his peril is
issued.My Worker's Compensation Insurance carrier and Policy number are:
Cron Policy Na.:
CHR 11 FICAUON OF EXEMIII ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not m completed if the permit is for one hundred dollars
($IM)or III,.)
1 ce.ify that'in the pertimnanec of the work for which this Peron'is Ismael.I
shall not employ any person in any manner sl,as to become subject to the Workers'
Compensation laws of California.Date
Applicant
Ndl'IC177 I'O APPLICANT:If atter making this Cenificam It 17sempOnn,You should '
Fecmmth
e subject In e Worker's Corapcnsalion provisions oLabor Code,the LabCode,yam mast
Q O ILnhwim comply with such provtdars.,,his par m'shall he deemed revoked.
fZ_^• ._�a CONSTRUCTION LENDING AGENCY
ai > 1 hereby al'lina that there is a construction lending agency for the performance
ot'thc work far whiah,h,pconft is isoW(.See 3097,Civ.C.)
L Q lender's Nano
Z Lender's Address,
V Q I canary that I have read this application and into that the above information is
Ls. F.t c rraet.I agree Ins comply with dl city mrd mun.y on in:n¢en and sm,e Ines reliam,
Q U
in buildlagcon.noted on,and hemhynummaee mpre.sciannive—I this city to enter upon
the ahove.ammloned nropm,ter inspection purp.,se..
L (We)agree to sme,indenmify and keep harmless the City of Cupertino against
V) Iiabll hies,judgments,costs and expenses which may in any way seem,against said
U .Z City in cometforce of the granting of this permit.
APPLICANT ON DHRSTANDS AND WILL COMPLY WITI I ALL NON-1101 NT Issued by: Date
SOURCE REGULATIONS. Y'
S ignamre of AppllcamConoaor Dae Re-ro0t.5
HAZARDOUS MATERIALS DISCLOSURE
Will fire applicant or Ca nm building ccapam.ere or handle ha..amau,ana l Type of Roof
ux detin d by the Cupeano Municipal Code,Chupwr 9.12,und,hc Ileuhh mud Safety
Coale.S,aion 25532(a)''
O Yes 0 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building aenpantuse equlpmemarell which If a roof is installed without first obtaining an inspection, I agree to remove
•mi'h:naMnm air connationals os defined by the Hay Arco Alt Quality Management
nnhicc all new materials for inspection. Applicant understands and will comply with
00Yes 0N all non-point source regulations.
1 have read the hamrdaus macnals requirements under Chapter 6,95 of the ,
Cali Coma Health at Sare,y Code,Sections 25505,25533 and 25534.1 kamcn and that
Ifbe, building docs amt currently louse a moat,that i'I,my mspano billly tin nail,Ina
occupant of the reco iraners which mus'he met parva ixsuunce of a Can ificam of
occupancy. Signature of Applicant Date
Oaraadrariv.aJ agent Dram All roof coverings to be Class"B"or better
OFFICE