02010064 (2) 11 1 i
CITY.OFCUPERTINO Q P M
.. BUILDING DIVISION - PERMIT CONTRACTOR-INFORMATION: -- l., ------ - -
821060RRED•.F.IR_CT:: ._.:__:, . _._:'_: -.-WATER.-HEATERS. ONLY--'*--.-.,. rERMIr.yG. ,; ;,:t•,.;
, .• .. . _._. ..___._.._:....._,._,_.02.0,1.0.0.64.:__....-.
' OWNER'S NAME: APPLICATION SUB DATE
COLLINS KAREN 970 E. MAIN ST, SUITE 20D01/15/2002
PHONE: (415) 566-2209 SANITARY NO. CONTROLNO.
ARCHITEC,ENGINEER: BUILDING PERMIT INFO
Qµ Fp�j BLDG ELECT PLUMB MECH
Z:d LJ L]
EiO LICENSED CONTRACTOR'S DECLARATION
5 a Job Descriptio
,2h IhercbyatBrmlhaJamlicensedunderprovisionsofChager9lcommencing REPLACE 40 GAL GAS WATER HEATER
with Section 7lN10)nf Division3ahhe Business and PmfessionsCWe,ondm license
iuI is in full fmccond of t 7 -
m a 6 License Cl. Lie.p.'-'
0 U Dae Comracmr -
t C G ARCHI'TECT'S DELLA TION
ig 1 understand my plans shall be used os public records
r
Licensed1 Mi p o
Licensed Nofesxional
-
OWNER-BUILDER DECLARATION
R m I hereby olfirm that 1 am exempt from she Contractor's License Law for the $700
t?< fall g reaso ISecct 7031.5Bui nes Profess
d ion.Coda:Any city or my
R❑ wh ch q t f e .coal toe ct Pte mprove demoli h - epa an structure
3 a :Pim , its leen al req i M apps a forsuch'permu toll ag gusement. - --- - - - - . --- - -- —now he is l cased pmgnint n the Pr3xn iv f He C treads V nee Ism ICNger 9 . ,�. ,,., a_ p,�q� 1„ .,_.
(mm Swith stat n7")yf Div on i am ) ',3 x'170- t _ _ .. Valuation . ..
drtNtN -e em tHcrtfrom eM tNb e - y i .,g--b.! `l .,,
-of Sector,703 P5 by anyappLearn for pe blas the I Pj mit ivil peodt ''e
of of Inn fivehundinddolloa(5500) -- t P cell ane Type
V R PLUMBIN t'ENERGY� P. Y YP
Basin.,dotand work;
n the n' .' . ' , a
12 Los ter The ro n arm em lo« esmt ole'. on; '_ ., ...
P Pe Y Y P Y _ .,.
% 'will donhe work;end she wnurc is not tided o oB- sale ec.704d;
esti Coda:The Contra .Luxmr d or Ply tom '7 - JAL PlbWffq�speetions
owner of property Who Wilds or improves t as Iuwi
•: or through his own employees.provided that I e o tended m
-offered for sole.If,however,the building ar tunprovcmem is old within one yea of
completion,the owner-builder will have the burden of proving that he did oat Wild or
improve for purpose of sale.).
111,as owner of she property,am exclusively contracting with licensed communist;to •'i
onswct the project(Sec.711,14.Business rid,Professions Code:)The Connector's
"
License co
d Law does nmp
aply man owner ofo
prperly who)lids se improves Hereon, ,
- antl who avxcfor such projec .wH anto
icocmrtq licensed Wrsuent.to the._... .
Conwnm's License
se law., I i - - -
❑Iamexempt under Sm. ' s "' '• .B&PC(or Hisrteson : .I':• �
Owner' Dae .. _.
WORKER'S COMPENSATION DECLARATION
Ihcrcby affrmtinder gnHry ofperjuryone o(the following declarations:
1 ❑ 1 hale end will maintain a Certificate of Consent to.elf-insure for Worker'.
Compensation, as provided for by Section 3700 of the Latta Code, for the
performvnce of the work for which,his permit is ismed.
'$I have and will maintain Worker's Coinpen.otion]two...m,as req 'red by Section
IDO of,he Latin,Costa,for the performance.of He work for which His pemdI is
issued.My Wo I C n os on Insurance camas end Policy number are
Camel`''Polley Na rlS�' ZGS'OI ..ys , 'r ..: I, 1' y.•f},xC IY...}. Tf - .. . . a _ . .
CERTIFICATION OF EKEMPTION FROM WORKE ,RS' - t '• r,• r'q^ •• Y• 7 T
.., ,r.. .. COMPENSATION INSURANCE: : . .. _ 's...]i ".x1: . .._..... �' - - ......
tThis section treed nm be comPlcted if,he permit is for ane hundred dollars
($100)or less.) , ... ...a.' ....... ... .......__. . . ..._...._..__ :_ . .. .... _.._ _ ..._.
•,( 1 sanity tat He pmformexe of He work for which His permit is issued,)
shall not employ any person in any minner so as to become.ubj t a He Werkim
Compensation Laws ofCalifornia.Date -
Applicant - I
NOTICE TO APPLICANT.If,ober meklnR this Ceni/cam of axempIf .you.hould -
.zQ Obecome subjectto the Worker'.Comp.2won provisions of,he Lobar Code,you must
forthwith comply with sd<hprovisions onhiO pertain shall he deemed invoked.
^'^ �CONSTRUCTION LENDING AGENCY -
t•^- 1 hereby effort that Here is a construction lending agency for He performance
of the work for which this Permit is issued(Sm.3097,Civ.C.)
�t Q lindefs Name .. ... .. .. ...._ .-
a;.Z L.cndai's Aikress
1 comfy thrift have rend this application and Orme that s b taws Ginn is I,/n
W.f"'i to Wil I agree,o comply with all and opo Ordinances d slaw laws enter
upon
� V
to
on.wed aiidM1ai "down uposemetives Df Hlcity to emer upon
rt, He aW c mens one.property for inspection purposes.
un (We)agree so sower indemnify and keep harmlcso the City of true against
st aid
'y City in cLo judgment,mets and expenses which may in any way accrue ageinsn said Cr l
V City n e n equentt of fee grmung of it. '
'APPLICANT,UNDERSTAIDS A' 1 COMP WITH ALL NON POI Issuedb � Date: '
r SDURGR REGULATIONS. rI � I Y
SignatureWiliiNnliclHAZA DOU MAT occupantmaemhe E ..., .mus mllle���t///al Re-roofs
HAZARDOUS MATERIALS Dcour ISCLOSURE '
Pp g " Type of Roof
ssdefinW by the Cupemro Municipal,Caude,Chapter 9,12 and HC Health slid Selc,Y _ -
Code.Section 25532(a)n r ` t h ( .. t • �. — Sd A a '.. _ . ...
ores ❑ro r,. All.roofs shall be inspected.prior to any,roofing matenal:being,installed._ ._. .._.
Will the appliunm or future Wilding occupant use equipment or devices whim If a roof is installed without
'I
an,inspectiori;dtagree•to remove
ami,hazardous Or containment as defined by she Bay Arca Air Quality Management
Dissrim7 all new materials for inspection. Applicant understands and will comply with--'
o.Yee C3 No all non point source regulations.
I Nva read He haiardous'materials"Onaments'uuder Chapter 6.95 of He
Califomia Health&Safety Code.Sections 25505,25533 and 8534.1 understand that
if Ne building does not cumantly have a recent,that it is my responsibility ro notify the - -
o6ewant of the requirements which must be met prim 10 issuance of a CeniRcate of
:'. Occupancy.
. 9 Signature of Applicant _ Dale -
owmernramm�riaee. of D.,e All roof coverings to be Class "B"or better
OFFICE