03010170 (2) CITY OF COPERTINO � 1"1
BUILDING DIVISION PERMIT CONTRkCTORIINI+ORMATION—
BUILDINGADDRESS: HOT WATER INC PERMITNO.
21450 MILLARD LA 03010170
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
KING NEIL C AND SILINE 01/28/2003
,ONE: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0, LICENSED CONTRACTOR'S DECLARATION
N-j G I hereby alum mal I am licensed under provisions of Chapter 9(commencing Job DCSCCIptIOn
m with Section]Otx) f Division 3 oss f me Business and Professions Crulc,and my license is ta�
zOyimm�rm��ndeffi . Z REPLACE WATER HEATER r�NALED
Z LicenSJJ°° Lic.M
y�,O Datc Conlractm
4oq� ARCHITECT'S DE A 1
e, a L crnand my plans shall he used as ¢reemds JAN 1 J 2004
cV
ce
uai 3 u Licensed Professional
f=LLm OWNER-BUILDER DECLARATION
1 hereby Norm that I am exempt from the Contmetors Licenw Law for the
BUILDING
p O following reason,n (Section](131.5,Business and Professions Code:Any cityor county
X m which requires a permit In co eruct,alter,improve,demolish,or repair any structure
prior to its isouance,also requires the applicant for such permit m file a signed statement
5� < that he is licensed pursuant to the provisions of the Conmacture Licence Law(Chaplet 9 Sq. Ft. Floor Area &0-anon
lig t—$ (commencing with Section 700)of Division 3 o the Business and Professions Code)or
that he is exempt memfrom and the basis for me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofe Occupancy Type
not more than five hundred dollars($501)
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do she work.and the structure is not intended or offered for aide(Sec.704L Business
add Professions Code:The Contractor's License Law does not apply to an owner of 506 6 — GAS TE y•nRC nspee M
property who builds or improves themnn.and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for aide.If, 507 — FINAL PLUMBING
howeveq the building or improvement is sold within one year of completion,the owner-
builder will have the burden of praying that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed con,acmrs to
contained the project(Sec.]IML Business and Professions Code:)The Contractor's Li-
ce Law does not apply an an owner of property who builds or improves thent and
who convects for such projects with a contractor(s)licensed pursuant o the Contractor's
License Law.
❑I am exempt under See. ,B&P C for this....
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for WorkcrsCompen-
7E]
ood,as provided for by Section 3]00 of the Labor Code,for me performance of the
rk for which this permit is issued.
1 have antl will maintain Worker's Compensation Insurance,as acquired by Section
rIh boli Code,fm me perfnrma cif me woryfor lb irnme: permit is is7lic mherare:Policy N.:
CERTIFICATED EXEMPTION FROMWORKE S'
if COMPENSATION INSURANCE
(This auction need not be completed if IM Ismail is formic hundred dollars($100)
in less.)
I certify that in the perforrnanec of the work for which this permit is issued,I shall net
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cer ilicate 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 shall he deemed marked,
Z OCONSTRUCTION LENDING AGENCY
F 'N� I hereby affirm met mem is a construction lending agency for the Performance of
Cli the work for which this permit is issued(Sec.31017,Civ.C.)
aLender's Name
Zoo) z Lender's Address
U Q 1 est ify mal I have read this application and sate than the above information is
IL w-r correct.I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize represimmovesofthiscitytoenter upon the
Oa abovetme mentioned properly rand extewion purposes.
(We)agree m save,indemnify and keep harmless the City of Cupeninn against
a,y y
liabilities,judgmcnm,cnsls and expenses which they in any way accmc against said City
U iAby:
PP NT n con f the granting of this perm it.
UNDERSTANDS AND WILL COMPLY WITH ALL N N-P NT Issued Date
'A lie EGULATIONS. pp
�et1710Re-roofs
Sigilse
werfodApplicam/Contruclor arc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant snore lir handle h tcaNrus material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Id,a"At
de,Scdon 25532(ft n / All roofs shall be inspected prior to any roofing material being installed.
El Yes 6
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
it haxoNnus air contaminants defined by the Bey Area Air Quality Management all new materials for inspection.
strict'
❑Yes o
1 have mad the haamdmus materials requirements under Chapter 6,95 of the Califon
aiding
currently haven a tenant,mal it is my respond bility to notify IM x.cupan ofme
nnswNchmuslMmmprinnrissunneeofaCenifica olOve an' Signature of Applicant Date
Ow ra�mmixedagent DDod, All roof coverings to be Class "B" or better