03030094 (2) CITY OF CUPCRTINOg'' 3s
BUILDING DIVISION PERMIT W ;
o 01iR�'4� NF
BUILDING ADDRESS: PERMIT NO.
WATER HEATERS ONLY '
22901 T.C)hlr, T)nWN RIZ) PERMITM
OWNER'S NAME: 970 E. MAIN ST, SUITE 200 -
DILTS C
SANITARY NO. LNO,
(800) 835-5946
ARCHITECT/PNOINEER: - BUILDING PERMIT INFO ,
l� O PLO O
j00 LICENSED CONTRACTOR'S DECLARATION - ]Ob Description - -
b 1ion70affirm Ihet1am Ibcenudundernd pmfnsof Chapter9(mmmendng - FINALED
with Section berab affix that I am Li thesed under
and Promsainnshapter and 9(Com(Commencing
np Inmufome.nde .3G Lm.«- 4-5 1 :71
REPLACE' WATER HEATER ,
p19 T� Llccnec ,.
�dCa pppppp De¢ r Comnnor SEP 1 LOOS
'7 ARCHITECTS DECLAR TION '
1 understood my plans shall be used An public rtrnrds
5A`
g0 LicensedPmfcoiond BUILDING
OW NE0.-BUIIAeR DECLARATION
.�� 1 hereby affirm Nal 1 em exempt from The Contactors License low for the
goo rollnwing rtunn.(Sonkm 7031.5.Busineat and Promuions Code:Any city or county -
a$ which requires a permit to convect,eller.improve.demolRh,or repair any structum
iy pdoruits lonsnce.Jw rtqulmo the applicant farwch permiuo rile a signed summenl V.alll , IT
< Nat he islkenseJ purtuenlm the provisions a the Cantrauni U.nse Law(Chapter 9 Sq.Ft.Floor Area ,y�5'- //UU OV
y` (commc.ing with SeeHon 700th of DiNslon]oftM Busima and Promuinns Codc)or
ell$ Nat he It exempt therefrom and The has far de alleged cumption.Any violation of A�57�7�7y�,,.tt
Semlan 7031.5 by am appllani fon permit subjects the.ppliunt to a civil penalty of 3 Y C YCJ1'I 4r 0 0 Occupancy Type
not mart Nen rivehundred dolma(5500).
0I,As Owner of de property,or my employees with wages an than sole mMPAMA ,
will do the work.and the atmcture is not Intended or offered for sale IS".70th.Bminea 502 - FINALRi4bWNHff*E£ti&KERGY
And Probous ans Cade:The Conuamr.Llceve law dual.1 Apply a an owner of
propertywhab.0dimloopm1a ft .and who dousuch work hlmselforthmugb his SO6- — GAS TEST
. . awmemployees,provided that such lmpMwmatsana nintendedoroffemdfarsaw.If, 507 -FINAL PLUMBING ,
huwevee the building or improvement Is said within one smu of eomplelmr,we owner-
builder will ban the burden of proving NJ he did not build or Improve for PurPM Of ,
sale.).
❑1,a,owner of the propaty.em adusivaly conuscdng with licensed conmadon to - -
construct the pmject(sec.7044,Bminw and Professions Cade:)The CnnmwlDes Ll-
more Law deal not apply to in Owner of property who builds or
l.morelawdealnotapplytoanownerofpropertywhobulldsor improve&woman.and.
' - -
who contracts for such pm acts with a conuacm rs)licensed pursuant to the Comraoar'a '
License Law. .
teUp exempt under See. .B&P C for this--a
r Dee -
WORKER'S COMPENSATION DECLARATION -
1 hereby affirm under penalty of perjury arc of IN following declarations:
haw:and will maintain a CcNriesse of Consent to self-Wort per Warkert COmPa-
atlan,As provided fm by Section 3700 of the lobar Code.for we Performance of the
wok for which this Permit I.laved.
�iC[Y1 hhn and will maintain Wmaeb Componaawn Insurance.As required by Semon
0700 ofthe labor Code,(or dm pafarmmee of the wok for which this permit is Issued. - -
My Workers Com nsn1.]a,.ce curler end Policy mumu..: -
C.Mer. �' �...= -Policy No. O 5111.3*0Z-
CERTIFICATE OF EKEM PI70N FROM WORKERS'
.. COMPENSATION INSU RANCE
(This section need not he completed if the permit is for one hundred dollars($100) -
'
1 cantly tha......
inthe performance of the work rot which this North la issued,I shall not -
e.play anyperson inany manmrsoamMason wbjeeuothe WorkerfCommmadon
Laws of California,Dau - '
Applicant '
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
became subject to the Workers Compeaetion provisions of the labor Code,you most ,
J Z forthwith comply with such provisions or Permit hill h deemed rtvokcd.
'yO CONSTRUCTION LENDING AGENCY
I hominy aR7sm that Nem its construction lending gency for the Performance of
fY.r7 the walk for which this permit it bound(Sec.3097,Co.C.) -
U]Q Lenders Nurse
z Loaders Address
U 0 I cenbfy that 1 have mad this application and rete that On,above Information I. -
V. cmmx9.I as.10 comply with JI city and county ordinances and tum laws mlating To
0
building ee)Ajpai n.and 1.a.hembywy Andmpmhenues;to this coymcater
ino Ago"t
[Sl .hove-mentioned property for inspeNan purpout.
y s,j.agreemave,Indemnifyandtech hay 1.An the City
ruCupertino gJnst
y inconseque dgmenW coamindexpcn&N which may In anYu'ey aasue.galnn old City
lU{
tJ 7 A P41CANT of UNDERSTANDS
of this Permit.
ri APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N9N-P'NT Issued by: Date
.. SOURCE REOULAT10N5.
Re-roofs
Stgnal me of ApplbcMUICOurtwo r Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof t
Will The applicant or future Building occupant tore or handle ho udous maudal
in defined by the CupeNno Municipal Code,Chapter 9.12,and the Health and Safely
e,It 11an 35533(&)7 Q . . All roofs shall be inspected prior to any roofing material being installed.
DY
al
WHIT the apPlicam or comm building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I h xAmous air conuminmts As dcOned by the Bay Area Air Oualby,Manegemenl all new materials for inspection.
ituict7
❑Yet Nu
I hove reed the hoard.,materials requirements under Chapter 6.95 of W Celifor.
ria Fiat"S fmyCade,Sections 25515.25533 end 25534.1 undenund That[fine building
does not curter I ham sant.thu it is y mapunalblity To notify the as I the -
myuirean tial dpdonl ....rlCemnatearo, /r. Signature of Applicant Date
Owner aranmedm gent Date All roof coverings to be Class"B"or better