01040006 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: IN'RMI'r NO.
OWN17R'S NAME I APPLICATION SUB DATE '
U 64 /03/2001
•PHONE: SANITARY NO. CONTROL NO.
1 —q
O G ARCIIITECI'/EM1'GINEIiR', - BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
r i E I.J 1=1 I=1 ISI
aN
L of heirIIr Chess.ACTOKS DECLARATION
z S y 6 1 hereby arnnn mm L,rn,licensed ender p,( rrchapter 9¢„ 'Ing - Job Description
�mFre with Section 7Dt4Bnf Div nn3ottheBusincs and Core and my li,,-,
ie n full be ant ellva.e -
Li�x,,.0 cm: Lie# REPLACE 50 GALLON GAS WATER HEATER.
aeO�" Date Cmnrneor
w 3 p y \RCHIr e u S DLLLARATION
f Ny; I J t I ypl 'hallby Iphl' I'
w
ad0u Ijwer,ed1 'I
OWNER-BUILDER DECLARATION
w I h n - Far pt ptf theContractor L 1' I The
F /
>� llv. w b (S f 7fR1513 .'and t .` Ca An, an t' toy
YF� Ith 1 p 'It lu l :,lt p J both, p Y - lure
C pr rh t 'lvo I Ih p..l'rn fi 11 n,ur .y dna¢mcm '
(ad
bath 1 dp ecta n m 1 rte c t Inds) I (a,Core) Sq. Ft. Floor Area Valuation
(an mg with Section 7onln of IJIv .- of one leBusinessdre and Pndony Qldc)
or Nei he lx 31.5 bt merefm,n:ed of a Pei%our 1,v,s'be ,Tfilarl to Any dlolndol, n
of Section 71D L5 iv any rigid rite fr a pern,il sunjed the applicunT e,u civil pcnahy
„rnottm,red,ann%ehandrendmmr.r$stxt). APN Number Occupancy ype
El L- of pmpcny.o my cn,pluym with wag,,ae their enlccompenm,ior, _
will do the walk.and the structure iv not intenMd ,,offered for sale(Sec.7144, v
Rusin..and Profession,Code:The Contractor'.v License Law sle,a apply ,,an a_ I equired Inspections
of proMnr Who bunds or Inpros Thereon.and who does such work himeeB
r through his ry unploye, provided that area.cosh v ,uh,are not ended n
or
for sale.lf.ho r,the ml ani ego n,prn em`I,,old iter one eel of 50i_ — FINAL PLUMBING ENERGY
m,piction,the(wner--builde will have the or
ed nrovins Thal are did n I nudd or �,•
inpnwealrnarpowotwle.). .406 — GAS TEST
❑1,a of theproporty.a xmusivelYcollee,wilhII naedcontractorsto - 507 — FINAL PLUMBING
Lon%tmc�e,pm)mt(See 7044.Routine,and vrobe,ouns Celc the Comracmr's
i,va-,Low does nol apply to w,owner el pmpcny,over hard.ur improves 0.+c,1,.
.n11J who onlaas for inch projeme ,In u conar,lo,(s)li,e.I pursuant to The
C,niraetel"l.Iceo.e 1,111. -
❑I are euempt ander See. B&P C for the reason -
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affrn,Indo penally of frory one of the following dre4rzl10nv. .
• ❑ I have and 1111 maintain a Cerliti if Conxnn to self-insure fur Wnrker'e
Cunllwn,aion, us pureded be by Se,bon 3700 0l' the Labor Code, fur the
porfmmrnce al ere work for which this permit is r,tral.
❑I have eld wd1 maintain Worker',Compensunon murmurer as overfeed by Semon
- 37tH)ly the Labor Code,Bar the pval'ormmince of The work fur which this permit Is
.red.My Work,,Con,pcnwtinn horrunce carrier and Policy number amt
Carrier: 1'o11ey Nov
CERTIFICA'T'ION OF EXEMPTION FROM W OKK12RS'
COMPENSATION INSURANCE
IT le,seetion need n r b vine,lemd it panni Is on one handled dollms
($10(h or less.) -
I really that in the pa,frrearc,of the work for which Ile,penen us flared.1 -
%bal l not criploy any per a„y I, r ao,t,m become.%Meet to Inc Workers
Cuntpcnaaion Laws of Cald her.Dutcnl,
Appncnm
NOTICE'fO APPLICANT.II;IIIc[mating Nle Cenllirdc of E.enpdrn,you should
Z hecomc sohJeelm The Workers Cumpcnsouo i provision,of the L1nor Code,yo nae .
Q fonllwid,comply with ,all pm sons or his per n'n shall be deemed revoked. ,
Z
y CON ST.ef's.ON1.ENDl NO leading
II V
a , hereby which that there t iv anrsell See,
landing agency for the perli,m,unde -
of the work Tor which thio permit i.Iv%ucA(Sc<.A)9].Civ.CJ
4 (,� Lender',Nair,
ha,dttS A4JI'drc,n
U Q I eertily that l have road nn'o upplienuun and.vote lea,the above internal to Ls
LTi �y e rave I agrm m comply with:dl city rnd mend,nnl'm:I and state laws sedating -
Q [) to ha'dding coastrreien.red hereby tmthorim repmorali hes of thio city to enter upon
the ahove-mentirned property let impertion purposes.
F y (We)agree it)ove. ndcnmify and keep hannlc.The City of Culxnino against
Ln liabilities.jodgmrntI.costs null expense,which may In any way accrue against said
C.1 z Only In con...I.I c of"the granting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. Y'
Signatureof ApburrouCtourrcter are Re-roofs
HA9ARDOUS MATERIAL 4 DISCLOSURE
will the rppiicam or future building(seclusion nom a hurdle h,.ardoes mtdedal Type of Roof
.is defnlud by(he Cupertino Municipal Cad,Chapter 9.12.lard the Health and Safely
Code.Section 25532(a)'1
1:1 ye, CNo All roofs shall be inspected prior to any roofing material being installed. -
Will TheappneantorWhere buld'legrratesatoewuipme,ordevice,whicl, If a roof is installed without first obtaining an inspection, I agree to remove
nfa hoard.....air coneminra ns defined by the Hay Area Air Quality Management
,ui%tdet^ all new materials for inspection. Applicant understands and will comply with
Cl Yes 0N all non-point source regulations. .
I have read tiro ed.arrlous materials m(Iriremcess under Chapter!95 of the
Cullforn a Health&S;dety Code.Suedrm 25511.5.25539 and 25534.1 understand that
Tithe nuilding does not amenlly have r hurm,mat'It is,is rcponsihilitY m noT'It'r the
Caapam of rile axptimmcnlx which host he Ire prior n, %seance of a Ceniticau,rf'
areful .
Signature of Applicant Date
Gwner rr au It .I agent Dane All roof coverings to be Class (`Bar or better
OFFICE