03010178 (2) CITY OF CUPERTINO "
BUILDING DIVISION PERMIT :CONTRACTOR INFORMATION:,,,,
BUILDING ADDRESS: HOT WATER INC PERMIT NO.
21370 RAINBOW DR n'AC)10178
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
VITTAL SPIMUSHNAM 01/28/2003
NI;: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECI'/ENGINBER: BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
fooLICENSED CONT xACrOR'SDECLARATION T jobDescri tion
n I hereby affirm ion
that 1 am licensed under proviss of Chapter 9(commencing / p
wish Scclian]INNI) !Division 3nf WC Busi unJ Professions CnJc dmyliccnsc is I
m nn�redandert y REPLACE WATER HEATER
Lirrftsc aa, LIc.N � -..�
F=Fr.q• m RCIBTTiLTSD ter 10 ✓ ���
o g� I unticrstand my plans shall M used puhlic records -
LLOLicensed Protestations]
OWNER-BUILDER DECLARATION
¢� f 1 hereby affirm Thal I am exempt from the Contractor's License Low for the
at following mason.(Section 7031.5,Business and Professions Code:Any city or county
°• $ which r.yuires a permit to amstrusa.alter.improve,demolish.of repair any structure
prior to its issuance,also requims the applicant for such permit to file a signed statement ,.h
Z< that he is licensed pursuant to the provisions of the Connector's License,Law(Chapter 9 Sq. Ft. Floor Area $tfg"tion
ec l-$ (cnmmencingwithS lion7gk0nf Division3ofnc�BusinmudPmfcssions CWc)or
�.- that he u exempt therefore and the basis for the alleged exemption.Any violation of
Sadon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ¢ 0 Occupancy Type
not mom than rive hundred dollars($500).
❑I,as owner of Ne property,or my employees with wages u their sole eompetuxlion,
will do the work,and the sanctum is not intended or offered for sale(Sec.7W,Business
and Professions Code:The Contractors License Law does Bat apply Io an owner of 506 - GAS TE elgmre nspecFINAt rots
1112
property who builds or improves thereon,and who does such work himelfor through his
own employees,provided drift uch improvements a o,not intended orol2md for sale.If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sal..).
Q 1,as owner of the pmptny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor s Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such pmjecu with a conmacter(a)licensed pursuant to the Contractors
License Law.
Q I not exempt under Sec. .B k P C for this..an
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aBirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Conenno self nsurefor Worker'sCumpen-
ion,as provided for by Section 3710 of the labor Code.for the performance of the
work for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance,se required by Section
31
1
)of the Labor Cede.for the performance of the work for which this permit is issued.
My�kma' q Insumnc. erticra Policy numheramCu ]icy N .:IFICATEOFEB 1PTIONFROMWO KERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is fume hundred dollars($1010
or IcssJ
1 certify that in the performance of the work for which this permit is issued,I shell not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Cioform.,Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compo mation provisions of the Labor Code,you must
OO forthwith comply with such Provisions or Nis permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
[..r N. I hereby affirm that from is a consu .tion lending agency In, perfmmarne of
y' the work for which this permit Is issued(Sec 3107.Civ.C.)
Iql Q Lender's Name
z Lender's Address
U Q I certify that 1 have read this application and sum that the above information is
U F cancer.I agree to comply with all city and county ordinances and sum laws mining to
C U building construction,and hereby autharim repmscnmtives of this city to enter upon the
Lk7 .hove-mentioned property for ttBpectom purposes.
(W.)agree In cast,indemnify and keep harmless the City of Cupertino against
f�q Iiabllili(Wdgrena,to case.and expenses and hich kepmayinanyw City
agmnino against
City
V7 in consequence of the granting of this permit.
L7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NQQQNP NT Issued by: Date
SOURC GULATIONS. Ii
� O7 Re-roofs
SIS core of ApidirmalCurtinat Palo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building oecupam sore or handle hazardous material
as defined by the Cupertino Mu �ipal Code.Chapter 9.12,and the Health and Safety
,deliVoc..Scmian 25532(.)1 All roofs shall be inspected prior to any roofing material being installed.
QYcs No
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
nazerdnus air etmlformanx a,dd,'oil by the Bay Arca Air Quality NNusiFment all new materials for inspection.
air's
QYcs u
I have mad the hazardnu nmrerials rec.iremcnu under Chapterfi95of the Cold.,
niallcilth afcty C, c.Scctiorts25505,25533.d2534.1unJcr that if the building
tires curet ly hast a mnan4 Na it is my respmsibility t notify M acupant of the
regremcn ichmustri.met poor inissuanccofaCertjfa¢af5yanc➢. Signature of Applicant Date
svne,minal dircdogcvat i1 0G 3LAam All roof coverings to be Class°B° or better