00120108 (2) CITY OF CUPERTINO
1111-ILDING DIVISION PERMIT CONTRACTOR INFORMATION:
[WILDING ADDRESS PHRMI'I No
20065 NORTHWIND SC WATER HEATERS ONLY 00120108
OWN17H S NAME: APPLICATION SUB DATE
TlING LESI IF C 500 AIRPORT BLV 12/18/2000
lie PHONE: SANITARY NO. CON'IROLNO,
(415) 349-3747
Qsm ARCHITECT/ENGINEER: BUILDING PERM,INTO
❑Q❑ IIhDO IiLECr PLUM[ M17CH
muU IJ 1=1 1=1 IJ
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oa5 LIa'UCONTRACTOR'S DECLARATION
Job Description
,4❑ 1 hereby Roamthat I am licensed ender provisions ohChapmr 9lronnnenci
with 5enlion7(XX)ofDvninn3o1h, {uonesnaW Pm@x,iuns Code,andmylicense� W ,
-+ mm rml mreeand elvo, REPLACE 40 GAL GAS WATER HEATER
z a a ])acme rWs, Lia.tr
jt+-,�i, AHCIiIIiCT'S DLCLARAI'ION
F Contractor
LL g 1 undeamnJ my plan,h ill IN axed us public record,
�r
w5 p O Licensed f
M I' , xionul
o i OWNI[R-IJl1ILUGR Ur:CLARAI'If1N
='m I hereby,lint,That I an cactnpt Ban,the Cnnlra,na,License Law for the
h z a fallowing reason.Isatin.703 L5.Badness and Profession%Cale:Any city or county
E S C which require,a permit to construct,alter,improve,demolish,or repair any,tructere
neptionn its issuance.vlsomquires the applicant lorsuch remrinto flea.signed statement
c. than he is licensed punuc:n,the provinionsof the Co nouif,License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 701)(11 of ON kion 3 of the Bit,nes.and Protev,wn,Code)
.,,but he is axerna brummn,and tire hais rot the alleged asenipliun.Any,iolmim, $70111
of Section 7031.5 by any oppliaanl for a pcmin objects the applicant to a dvil Penalty
.fruit in.than five hundred dauar,(sslft A PN Number Occupancy Type
❑1,no,owner ofthe property,or my employees with wages as their sole cmncraran. 71 F,3FHrA07_ 1710
will do the send,and the,miclum i,nit amended err uttered far nate(Sec.7044
1{msinmx and Pmressla,x cam:The Contactors License Law do-1 t apply to an Required Inspections
none,of pmpeny WI,m builds or impmsas menton.and who does such work himself
or through his own employees.provided that such improvenrnts are not intenkal or 502 — FINAL PLUhIB I NG ENERGY
ethernet fan sale.If,hnwoar,the building of Impmveman ix sold within one year of
completion.the owner-hmilderwillhav�emehanlennfposing that hedid not huildor 906 — GAS TEST
nnpmver pmrpma if sale.).
507 — FINAL PLUMBING
❑I.as owner of the pmpeny,ma exdavivdy cumtaning with licensed contractors ro
L,mtmet the Pmjen(See.70,0.Basin,%and Prnfcssiuns Cade:) Fire Contractor's
icense law dors nol apply to an owner of pmpeny who build,or improve,thereon.
and seta contracts for such pmjaa with a cunaavems)licensed pursuant to the
Cnnvucn,r'y License Law.
❑ PIM'N
Inlll exempt ander See .Nk Cli,r trn
is ano ALEp
Owncr Dam
WORKER'S COMPENSATION DECLARATION
I hereby afirn under penalty err perjury one of the following declaration,: OCT 10 2001
❑ I hove aid will maintain u Ceni icam of Consent to,alt-imare lir Worker', ,1
Com,emation, as provided for by Section 37m) of the Labor Code. for the BUILDIIV
perhonnence of the work for which this permit is issued. G+
❑I have and will muinain Worker's Cnmpenwlion Insurance,as required by Section
37111 or the Ichor Code,for the perm umac of the work for wbleh this permit i,
,sued.My Worker's C'nmpcn,win i Imam ce auricr foil PVllcy number an:
Carrico Policy No.:
CERTT IFlCAl'ION OF EXEMPTION FROM WORKERS'
COMPENSAnON INSURANCE
('IT1, actin,need um M c..n...,,d it the'unit is for one bmoul e l form,
o I o(0 or less.)
I cenihy that in the performance of the work for which this P[mril is issued.I
shall not employ any Irrssa in any manner so as ,,hecamc object pt the Worker'
Co one...If Law,of California Date
Apia:nil
NUI ICE'1 O APPLICAN L If,after making mi,Cenilieaa o1'Exemption,you nmmId
Foci se amjmI o,the W..kers Compcnsatinn provision,al the Ulm,Code,you must
Q O forthwith comply.ithouch provision or this email shall IN deaned revoked.
Hy CONSTRUCTION LENDING AGENCY
a , I heathy airun.amt none is a c,n,tion on lending agency lin the performance
of the work rnrwhich this parotin is Issued(Sec.1097.Civ.C.)
6. Q lender's Name
5 Z Lender',Address
C.I 1 certify that I have read this upplication and slate that the uMve information ix.
F: come,,.I agree m co..in,with all it,and county onlimmee,and,taro laws relaim,
Q V to building uoust ucliin.and hereby nahorim rcporcmmtivcs of duk city,enter upon
(s] the nhnv-n,antioned property lir mope,on purposes.
FDs (We)agree to nave,indemnify and kmp harmless the Cit'of Cmpcnino again,
h I abdilics,judgments,casts and expenses which may in any way acne against said
U Z City in consaqucae of the'naming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-MINT Issued by: Date
SODRCERE ULAI'IONS, y'
Signamm of AppheaMConmc,r 1)la, Re-roofs
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or home building occupant,ore or handle hwadoas mammal Type of Roof
as deired by the Ca,vnino Municipal Calc,Chapter 9.12,and the livalm and Safety
Calc,Satin,25512(a)1
El ye, ElNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicamorfar..haAdingoeeupenl ua equipment or Jn'iea,which If a roof is installed without first obtaining an inspection, I agree to remove
coil haarnon,at'conaminants as defined by the Bay Arca All Quality Management
Disarm? all new materials for inspection. Applicant understands and will comply with
❑Yes 0N all non-point source regulations.
1 have read the home]),namrialk rcquiremanx under Chapter 6.95 of the
California Heath k Safety Calc.Sections 25505.25513 and 25534.1 under and that
if the building dies nm cure rl,have a moon.that it is my mspmdbilily,purify the
occupant of the regmimme ns which rotor In met prior,issuance of a Certificate of
caaanuncr' Signature of Applicant Date
Owner naathnriredamn, Dale All roof coverings to be Class "B" or better
OFFICE