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03010179 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTORdNF©RMATIQN: At, .. BUILDINGADDRESS: HOT WATER INC PFRMrr NO. 11021 LUCKY OAK ST 03010179 OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE GARRIOCH EVELYN D 01/28/2003 41 PONE: (650) 298-8494 SANITARY NO, CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �00 LICENSED CONTRACTOR'S DECLARATION E rraa�,�aate�,he u F I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOe5CP1 OyZnUj with Section 711(111)nf Division Ld a usimcaaamd Professions CrvJe.ond my Inch.is t' 1U. yREPLACTERYHEATE ZOMZ Lic 1 re.N _ OO w€p Date Cunuazmr /�J,f.� > 5 ARCIII'ItiQS�ECLA A 10 XR C< I undersunJ my plans shall lwadtfl as public recoNs E:HU _LL0 E Dil Licensed Professional OWNER-BUILDER DECLARATION se S I hereby if,.that I am exempt fntm Ne Connector's License Law for the w a a O following reason.(Section 7031.5,Business and Profcarma,GNc:Any city m cuumy k$E� which requires a permit set construct,alter,improve,demolish.or repair any structure w�°' prior in itsissuance.also requires the applicant for such permit file a signed statement Q�Z< that he is licensed pursuant to the provisions of the Conractins License Law(Chapter 9 Sq. Ft. Floor Area $Yc"tlon $�$ (commencing with Section 70001 of Division 3 of the B uaineaa and Professions Code)Or Nat W is exempt Btcrefrom and the hasis for the alleged exemption.Any violation of Section 703 1.5 by any applicant for a proton subjects the applicant to a civil penally of e Occupancy Type not more than five hundred dollars(SSIXE. 1,as owner of the propcny,or my employees with wages as their ante compensation, 502 will do the work,and the structure is not intended or offered fur sale(Sec.7044,Business and Profusions Code:The Cmamitur's License Law dces not apply m an owner of 506 - GAS TE ggwred nspectl(ns RGy property who builds or improves thereon,and who does such work himself or through his own empinnes,provided that such improvements aro not intended or offered for rate.If, 507 — FINAL PLUMBING however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving Nat he did not hit Id or improve for purpose of sale.). ❑1,as owner of Ne property,am exclusively committing with licensed contractors to construct the project(Sec.7144,Business and Professions Code)The Contractor's Li. muse Law does not apply to an owner of propcny,who builds or improves thereon,and who contracts for such projects with a commit licensed pursuant o the Comin toh License law. ❑ l am exempt under Sm. .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I hats and will maintain a Cenificam of Coosem to sel6insure for Workei sCompen- starm.u provided for by Section 3703 of Ne LOW,Code,fur the performance of the W ork for which this permit is issued. C 1 bars and will maintain Worker's Compensation Insurance,u required by Section 3700of the Luber Codc,for the performance of she work for which this permit is issued. My WorkctsC satin umnce ca 'cr and PFyJIka number art: Carne + P Joey o. CERTIFICA 0 EKEMPT ON FROM ORKEERS' ` COMPENSATION INSURANCE mchi section neat not tecompleted if the permit is forte hundrcddnllate(SIM) ,it less.) I ccnify that in the performance Of the work for which this permit is issued,1 shall nut employ any Nixon in any manner au as to become subject o the Workers'Compensation Laws of California.Date Applicata NOTICE TO APPLICANT:IL after making this Cedilicate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must O z forthwith comply with such provisions or this permit shal l he deemed revoked. zO CONSTRUCTION LENDING AGENCY [-+ tN—t I hereby affirm Nat there is a commoiction budi ng agency For the performance of IS! 7 the work for which this permit is issued(Sec.31197,Civ.C.) 0.W A Lender's Name z Lender's Address U Q 1 certify Nm 1 have read Nis application and state that the above information is W F correct.1 agree to comply with all city and county ordinances and state laws relating le OU building conswction.and hereby amhori,rcpresemutives of this city to enter upon the abuse-(We)are property for Inspection keep ha G (We)agree to save,indemnify and keep harmless the City o Cupertino against 0 inconiequudgments,coatsen,ex penseswhich may in any way acame against said City U iAnPPLx I%UNDEence(if tho RSTANDSif IANhis D WILL COMPLY ITL ALL NON DINT Issued by: Date SO C EGULATIONS. Re-roofs t,nature ofApplicaHAZARDOUS MATERIALS DISC OSURE DataType of Roof Will the applicant or future building occupant more or handle hamNous material as defined by the Cupertino Municipal Code,Chapter 9.13,end Ibe Health and Safety Code,Section 15532(.)'t All roofs shall be inspected prior to any roofing material being installed. ❑Yes �u Will the applicam or(inure building occupant usccyuipmcmordevicca which If a roof is installed without first obtaining an inspection, I agree to remove it haamdnus air mmamiamus.deftncd by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yea (�N. I have mad dm hanNoua mabrialsrtyuiremcn¢un4r Chapter fi95ofrhe Califitr- .isHealth&Safety Crate,Sections 25915,15533 and 35534.1 undersand Brad if rite building Jces t cutrendy here a tenant that it is my resrymsihiliry m tat y IM upon of Ne q whicbmumbeme,priormlssssmnmofaCcn¢ ratupan Signature of Applicant Date OwnernramhoriasJegcm / Dam All roof coverings to be Class "B"or better