01010050 (2) C1 BU'OFNCUPERUNNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRIi.SS PERMIT No.
22057 MC CLELLAN RD HOT WATER INC 01010050
OWNER'S NAME: APPLICATION SUR DATE
RETEKOS JACK G TRUSTEE 2531 GRACELAND AVE 01/12/2001
PHONE. SANITARY NO, CONTROL NO.
(550)298-8494
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F�< LICENSED CONTRACTOR'S DECLARATION Job Description
L
o'z_o I hroa
ereby art n I at bectrwd under pnwisi9m
n.,of Chapel 91ememing
P==� with Section 7NX0 of Divixinn 3 ofthe 13mine—ad ProtJ.axmnv Cods',and my licca,
< is in full hate and thea.
s < I:i«•n,cros, x REPLACE WATER HEATER
a`<P a`-' One Contractor
re 3 C ARCHITECT'S DECLARATION
g 1 undentuW my plam,batl W u,J os public rctori
m at< Liccn,d Professional
,6oO
the,I OWNER-HUIhDEH D[CLAR6raON
'u K- I hereby ostia than 1 1, exempt Tann the Contractor's License law for IM
ZY .1hichinguire,atenniton]IliLS.adlesnnd Pte. enioli Cal¢nteiray stcuunty
ce o isn1 I P n I I I f p I f.l p Y,structure
'L 3� prat t L. y hilt .\:In. tf I p II I I ''g J hant,m
noel 1 wdpnrw, tt ( n i fd Chmitine" soLaw fe,coc9 Sq. Ft. Floor Area Valuati )
fcoumhmemg with section V01X0 ill'Ili Nei, l of me liuxineas nnJ'Pnn Anion,CWeI
oIr deal M1e i. ntpt mem000,ant or Nei, sore cts the r ammo,,Anydinlnall, $SIDID
f$ocean➢U LS by ane dredd llforupetnit,,hien,the naalicum mocivil renuhy
of a.t mom man me nattered dollar,Issllol. APN Number Occupancy Type
01:¢owner of the properly.m eny employees with wri their,ole compenwtion, 397113023.
will do the work.and the structure is not intended or allered far sale(Sec.1044.
nuxinces and Professions Calc:Il.e Contractors License Law does not apply to an Required Inspections
sof property Who build,or improves themon,and who duce such work himself
or through his own employees,pmvided that such improvemmns am not intended or 502 — FINAL PLUMBING ENERGY
offered for suit.If.however,the building or improvement is sold within one year of
Impletion,the owner-builder wilt have me harden offaroving that he did not build or 506 — GAS TEST
completion,for pvrpaseof,Wc1 507 — FINAL PLUMBING
01,ons owner of the proper.,am exchcskely convecting with licensed Contractors m
Lm,huct the prospect(Sec.7(94,Business anti 1'ndess r,Cale:)The Cuntmemr'a
locne,Lawd.s,not apply ,,an owner of pmpeny who builds or in i m n,mention,
and who cnnvnctn 01r such ptnjmls will. :.,..vv:mrmgs) li"e"d person,to It,
Conuxaor's l,ccnw laws
0 I mu excnlht Under Sri. .It&P C for this reran
Owns, hall
WOR KEW S COMPENSAI[ON DECLARATION
1 hereby atfrin under penalty of perjury,one of the falh,wing declarations:
0 1 have and will andinsin a Certificate of Convict 14)self-insure for W'odeT's
- Compnsmion, as provided for by Section 3700 of the Labor Core. for the
ptonoance of the work fill which This permit is issued.
01 have and will maintain Worker's Compensation Inwmncc,as required by Section
371X)of the Labor Code,for the performance of the work fop which this Permit is
sued.My Worker's Comrenerion Inwmncc currier and policy maedi are,
C'arrlur: Policy Na,
CER'rIPICA'MON OP EXEMPTION FROM WORKERS'
COMPENSAr1ON INSUIXANCE
ffhl,welion need not W mn.p10111 it the plrmit In for ane hundred dollars
SI WI or 111,1
1«Wily that in the rerlbm.ance of the work for which this permit i,issued,1
shall not employ any pernun in any manner a.a,u.hecnme subject to the Worker'
Compensation lane of Cslifomiu.Date
Applicant
NOTICE 10 APPLICAbi If,after making this Cenificam of Eaen.ption,you should
Wim nuhjeo w the Workcrx Comremaimm pros sums of the Labor Code.you must
Q O fonhwim comply with such provisions a this peril shall W deemed mvoked.
z Vi CONS`T'RUCTION LENDING AGENCY
> I brachy aaimr that there is v consmetion landing agency for the prfntmence
W ill the work for which Ibis permit n issued(Sec.3O)7,Clv.C.)
0. Q LcnJcr's M r
5 z U, Ila',Addres
U O I artily thea l have read thi—pplication i I vol I".1 the above infocmilam i,
tY f~"t correct.I ugnar to emuply with all city and cuunty mdlnun .,and ower It,,slitting
U ,,buildingum.vmslin ,and h,shy allani,ncptcwrflabmof in,city In timerupon
the a,won scdo W amply far inspection parallel.
F y (Wo)agree m save,indemnify and kap harndes,the City of Cuprtino against
C4 liabilities,judgmems,cons and expenses which may in any way uccom against said
U z City in comegrenee of the granting of this remit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
Signature of ApplianatConmanor Date Re-roofs
IIAZIRDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding attafam wom or handle haanduus Uaemal Type of Roof
us refined by the Cupertino Municipal Code.Chapter 9.12,and the Hcahh and Surety
Code Section15532(a)P ❑No
0 yet All roofs shall be inspected prior to any roofing material being installed.
Will heaaphradorfuture brildnggerunc i legaipmednrdlsiee,which If a roof is installed without first obtaining an inspection, I agree to remove
midi haewdnux air conmmiona,ahs defaced by tat Bay Ale,Aa Quality Mana,mat
)IN11 t7 all new materials for inspection. Applicant understands and will comply with
ID Yet El No all non-point source regulations.
I have rad the hamrdnos morriah syuirancnl,ander Clec er 6.95 of me
C'afilnrnia fleallh.G Safety Code,Sections 25505,25533 and 25534.1 umb,mnd.hal
it the building d.w,nor cmarialy have a moan',that it is any re,ip ihility Io nmifythe
oacupum of the reyuirenat which must b:met prior to issuance of a Certificate of
Occupancy. Signature of Applicant Date
Owner or amoriecJ agent Date All roof coverings to be Class"B"or better
OFFICE