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crry OF CUPERTINO
CONTRACTOR INFORMATION:
Bun.DUNG DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME.
APPLICATION SUB DATE
121011
IONS:
_ —
SANITARY NO. _ CONT ROL NO.
ARCIII'I'ECrIEN .INFER;
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BUILDING FERMI IINFO
BLDG ELECT PLUMB MECH
I= I=1 I_I I_I
hICI.NSFD CONTRACTOR'S DECLAIN'IION
Description
I Lerch, allinn that I ren licensed under,u,i,ci, u, ol'Chapter 9 (colon encing
,lob
with Sc,rion](XXI) rat Div nn Sol the l{usincsx and l'n,ressiom Calve. and mylittn.
isin full farceam l cdc".'v'
t.—Cla%e Lie#
REPLACE 40 GALLON GAS WATER HEATER
Date Contractor
ARCBITECre DELLA N
'S E
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ie tee
I undcrstanA my pl... hall he public rcavvda
LittnscJ Rnlcssinwl
OWNER -BUILDER DECLARATION
Y -
License Law fm the
1 hereby affirm that 11. exempt from the Emmons
ProfcsntoliCWc:Any city lircounty
Cu
aftesand
which )•quires a ecnnid ,ellen improve. mcture
which repair any mtement
require, h Narrit t file statement
pro rn)slcensedIF.ulnaramIthe the a[,mitol for such tolilea
Sy. FI. Floor Area
Valuation
Law
in,,,rhanceericicoxdpunuant lathe pnw,sionsafine cnnlracinexs.indi)r law(Chepter9
is with Satins IlXXq of Dl virion and r eCale)
the Ih,ed
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.of
a rnprioto Any vinlflum
,,, hat It, ro i .Ary
thin ha i. and the hacix for ,heels
rnalty
li,r500),scrinutsobjanlM1cupxplicunr lnadvil pcnuhy
A 31.5 ht any fit tire
of
APNNumber - — -
Occu at e
P Y P
;,r nota n,an nae 1,am1r<e anuan. (ss(Xn.
nota,l,ulium file
❑ I, ns owner of the cmplayres wide wages un eaif orfs c mien.
J '6361368.
Inspections
andthe ler (See,
w111 tit) (lie work. and the 4.an
lTha is not intendedisI. lir olrcaA for rule (Nal.
r's..kens L:aw nose not apply u, a
1{u.% ;nW Patten s mic The Contractor's I(,
squired
builds he
of prvpcny WhoonbuilJs err imprints thereon, and who Jas such work himself
it rough his own employees. provided that uch impmvmnenlc are not intended or
orr
502 — FINAL PLUMPING ENERGY
offered Ire %ale. If, howcrer, the building or impmvcanean is sold within one year of
ntpletiothe (nrncr-builder will havcthe burden of pmeing that he did nobuildm
ion.
506 — GAS TEST
mprove for umpnu of sale.).
507 —,FINAL PLUMBING_
0 La: uwnernflhe pmpenv. ani CWksivelycomructing with liceisedcomranors to
antrum the prject (Sec. ]W4. Business and I'mfoeionx Code:) The Contractor's
License Law doe% not apply to an owner of mupeny who builds or improve thereon.
and who contracts% for such projects with a comramorts) licenced pursuant n, the
Control License Law.
❑ I an camp, under Sue _. INe PC for this
o r Date
WORKER'S COMl'ENSACION DIiCI.ARA'I'ION
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1 hereby alii n under pcnulty of perP;ry one of the Iullowiny declarations:
,] I have and will n rimnin a Cenifie,w lir Cnnsnn to .elf-ir u , it,, Wndcts
Camprnanion. ;is provided for by Section 371X1 nl tied Timor Code, for the
performance of the work for which this permit is oteiL
01 have and will maintain Worker's Con,rcmation Insurmae, m required by Section
3](I0 of the Labor Code, for the performance of the work for which this recruit is
sued. MY Wmlo,(s Compensation Insurance cancer and Policy number arc:
carries Policy iso,
CER'TIFICAT1ON OF F.XEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if IM permit is for one hundred dollars
Sid)) u,
I catty that in rbc putunnunte o1'rhe work It, which dhls pantie is issued. I'
s1ed1 crud muplo, any pcaon in any munucr cu us m bmcamte ser ',,n u, the Workers'
C a,a"adun Laws of Culih,mia. Date
Applicanl
NOI'ICE'1 D APP%ICAN'n 11, of,.,nnnking mix Ccnlfinvc ul Excrnptiun, you should
Leconte subject m the Woke/s Compen,mion pmvisinns or the Labor Code, you matt
'
lonhv.'ith comply with such provisions lir this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby ali a that there is a cuumor,pion lending asency fordye peafonnan«
lir the work Are which this permit is iemed (Sec. 3097. Civ. C.)
LenJds Name
Lealcr's AJdreu
I cenifY mm I have read this application and mere thm rbc line mfomlmion is
correct. I agree to comply with all city and county ordinances and stale laws relating
dvf this city to enter upon
In budding ca nxuuaion, and hereby authorve lepresnuae o
the aMwe.memtioned Property! r inxpec ion purpnsee.
(We) agree Ir.%avn. indemnify and Wit, hinnies, he City or Cupcnino against
IIalulldes, judg;nems. costs and expense% which may in any way accrue ngainsl %aid
City in con sn yucm'c of the sedating of this Ieumil.
APPLICAN'FUNDERSTANDS AND WILL COMPLY WI 111 ALL NON -POINT
Issued by: Date
y'
SOURCE REGULATIONS.
Re -roofs
N'lgmmure of Ap,kaul/Contraaaor Dat,
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicanl or future building ceecranl sure, or handle hm,udgas rnmenal
Type of Roof
as defined by file Cupenmo s1onlcipal Code. Chapter 9.12, and the health and Safety
code. Section zs532(m.,
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All roofs shall be inspected prior to any roofing material being installed.
Willtbe up kta, or future building aecupmm use cyid neem err Jcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
n I hurerdou.e air contaminants as defined by the Ray Axa Air Quality Management
i;nicr.
all new materials for inspection. Applicant understands and will comply with
OYe 0 N
all non -point source regulations.
1 Wave read the ha..ardnus mmenals Iuquircineanx under Chap er 6.95 of the
Cali forma I Icallh h Safety Cock. Sections 25505. 25533 and 25534. 1 understand that
if the building doe, nor curcnfy have a tenant, dint it is my respn;nibit ity It, unify the
nccu ism, of the rcquirmnen6c which must be or, prior Io presumes of a Cenilk,le of
Oaupanty.
Signature of Applicant Date
All roof coverings to be Class `aB" or better
I
0wae,ornnlba161e11 Dat.
)gem
OFFICE