01020106 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10540 N PORTAL AV WATER HEATERS ONLI 01020106
OWNER'S NAME: APPLICATION SUB DXI11
GUINN ORVAL C JR AND W NDA W 500 AIRPORT BLV 02/20/2001
PIIONr:: SANI1'AR\N0, COM1'IHO1.NO
(415)349-3747
Cat ARCHITEL'UHNGINEER: BUILDING PERMITINFO
8 IILUG ELECT PLUMB MECH
>�_ LICENSEDCOSTRAcroR'S DECLARATION Job Description
o%4 1 ber.by tddm.root[au.Ii,c—d,.mlcr p.a.l Won,of caalner 9¢amn9cncing
FF�P will,Scot on7fHv
HpnfOi,ien311 t he Booncsn lad ProtcWonx Codu,aal It,y l iccnxe
P-a 's in full force and eirro,.
R cg a a is in Li,.a REPLACE 40 GALLON GAS WATER HEATER
R 0e, Date eommc,or
lu3 �
e.< ARCHI'IECFS DECLARATION
C t='00.l 1 n
unde ,and my plmrs,hull he uwd as public record,
n
uc,r O O Lianwd Profcuinn:d
°. OWNER-BUILDER DI!CI.ARArHtN
t1++71 1 nercby amen ma,1 ren email from me CI baclor',I.menxc Law for he
C% follca ing moons(Section 7031.5.Duane„and Prof,,,kas Code:Any city orcvunry
—x e which require,a permit to comtmn,alter,improve.dnn9lish,or repair any structure
prior to its munncq also requires the applicant for such pernir to file a signed statement
'net he is licensed HuT%reint to[tic provisions of the Contractors Liceiric Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commcnciny with Section? )(hof Divi,ur30l'the lbl,inmsand Prnf xions Code)
lir Nat he ix eacnlpl tl,emtmm and tall htui,Ra the alleged umnptinn,Any violation
of Seen 17031.5 by any offib,on,In,a permit s.h,O,,the arrllcan.to a civil,o,illy
of not mom than live hundred dollar,($5w). APN Number Occupancy pe
❑Las caner of the rarely,or toy employees with wages as their sole compensation. an
will do the work,and the aromure is not intended or offered for sale(Sec.701
Ha,Ness and Profession,nde,'D,c Commends uccnie Law Nue%nm apply ro an Required Inspections
ld.r of povtc,Who bath.or in.pav-d,ereon,and who doe.,aeh work Mm,eif .-
.m.gh to,ow. en,.rloycea.provided Nn„uchiapav Dols area I imcnd,d 502 — FINAL PLUMBING ENERGY
„n'ead fol ate.If,however.the wild:...or irlIs..ic.n i-old'wiChin one yea,of
inmpletbn.theowacrhailde,wurnave Ne hurdenof proving that he did ass,build or 506 — GAS TEST
mprove bit p.,—of sale.). 507 — FINAL PLUMBING
❑1,a,owner of he property.am enduci,cly[ortn ing with hem¢ed comrnamrs to
a,nstaum the pa,lect(Sen.7wq.Radne,x and Pnofcs,Inn,Code:)Tnc Commear',
nd who doe,ore brNy.o;..,owner 9r aromrty who lice rte:.,,pave,t to the.red who Downs for.web pmjca,with a ennoue.nr(s) liecmed poli num m,Ne
01 no. sc �licam•c law.
❑1 ane eaer„pt anger See. .e&PC lhr this reason
Owner Date FINALED
WORKER'S COMPENSATION DECLARATION
Ilm.chy altmoCmlc,Ima:.IynlPerjury nncnl'the lbllowing declanniun"' - OCT 2 4 2001
O 1 hmc and will maintain a Certificate of Consent m wlf-insure lin Worker's
Compcn,mu,n, as provided lin by Semon 3700 of ,he Lahor Code, for rbe
m
I,eRoranen of,he work for which Nis tenni,is issued.
❑1 have and will nalinmin Worker's Compcnsalion Insurance,as required by Section BUILDING
37W nl'the I:abur Cndc,In.the Pcrl'om;m
lce of the work Tor which this pantu i,
„red.MY Winker',co.npcns;nh...In....aa,e Corrie,a roh,y aumbe,are: .
Cartier: Policy No.:
CERTIFICATION 01s EXEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
(Trak section need not be enn,pleed if the permit is for one hundred dollar,
($1 CHI)9r lend
1 ccmHy Chat in The porforneace of the work for which this rcrnni is issued,I
,hall nor employ any person in any Donner-as to necome subject to the Workers
eanpen,ation Law,of California.Date
Applicant
NOTICE TO APPLICANT:IL afmnnakin,bi,Ccr ificatc of Exemplion.you,huuld
become subject to the Workerx C(n.run,a,ion prisiors of the Lbs Code,youm.
O forthwith comply with ouch powkion,or this peril shall he deemed.evoked. n
Fr_ CONS1 RUC'I'ION LENDING AGENCY
.� Ihmchy;diinnram rhe,,i,ue,m,9uNon lendingagency fordle wifnn.
the sank lin which Ni,pscal,is issued Sea.3097.Civ,C.)
SQ Lender's Nome
5 4 Lender',Address
Q O I certify Ibal I Imve read(his.IppRillkan a nrec.ho Nc above im5,a,mio„is
W (lir correct.1 agree to co.nply with all city mrd enemy ordinunces and„mc law..relining
mwildin,c...olotion.anJ hereby unrhomenprcsnnmives of Nixcity loente,ti,n
} �] the abwonlemioned Paulsen,,fin tnvpeedon punooes.
(W'p ague to save.indemnify and keep hanalcns the City of Cupertino against
U (/1 liabilities,judgments,eo,1,and e,lwn,e,which,nay In any way ocems agannsr said
City in conse,nence of the granting of this return
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Dale
SOURCE REGULATIONS, y'
Signature(it Apprc,mtrcommctor u:ne Re-roofs
IIAP.ARDOUS MA'I ERIAI S DISCLOSURE
um the applicant or ru,ure building occupant store or ladle ha amens material Type of Roof
as defined by[tic Cupnino Municipal Code.Chapter 9.12,and the Ileallh and Safety
Code,Section 25532(x):'
oven 0 N All roofs shall be inspected prior to any roofing material being installed.
Wid Ne.appaeamormmre haddmg o¢upaal are egaip,ncm maesa"whlen If a roof is installed without first obtaining an inspection, I agree to remove
cold ha ardou5 air conuminams a,defiled by the(lay Area Air Quality Managcmem
Di,lrim all new materials for inspection. Applicant understands and will comply with
❑Yca [3 No all non-point source regulations.
I have rend.he hamNnu,mamriols requirencnts under Chortler 6.95 of the
Culifomia Ilcul.hh S:d'my Cuda ticco.....25505.25533; 125530.1 undadload,hnt
If,M1,building doe,nal curantly hove a mmmn,that I.in illy res,nWhility Co amity dm
cupan,of the rcquirancnfa which mu„he mit print u,issuance of a Cenificate 91
Occupancy. Signature of Applicant Date
Ow.neroraallorocd agent Date All roof coverings to be Class"B"or better ,
OFFICE