02020121 (2),....",,...: _ OFFICE
CITY OF•CUPERTINO ' -
Bun.otNc UIVIsION, ..
PERMIT: x; .::,,
; CONTRACTOR INFORMATION:
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BUILDING ADDRESS: "
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PERMIT NO I
i 3:0381-,RI-VERCREST CT;
{ JUST WATER:.'HEATERS,,,IN_C ..
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OWNER'S NAME: v--..-• -..-,.--'., .-:,•-'+p.....r _._ ,.L...,,...
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APPLICATION SUB DATE. ___ ..._ ..
BYLIN.ROBERT E AND'SEVERENE''
1764 NATIONAL AVE
02/28/2002
PHONE:
SANITARY NO. COKfROL NO.
(510)293-9901
17
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
L
BLDG ELECT PLUMB MF -CH
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LICENSED CONTRACTOR'S DECLARATION
Description
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1 hercq affirm that; am licensed under provisions of Chvpmer 9(commmiring-
with Section 7fIULDirision3oftheBusiness and l4okssionsCmde.and mylicense
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REPLACE WATER HEATER.
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is n full farce and effect.
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(4 0 GALLON GAS)
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Dat[ . cent.[+.,
- ARC DECLARATION
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hall he use
,1 understand my plans shall W used as Public records
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LiccnscJ Pndcesinno I
OWNER -BUILDER DECLARATION
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I h[rcby ufhrm that 1 am exempt from the Com.aar's License Law for the
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following reason (Sadion ]IULS: Business end Pmfcsninns QNc: Any ciry,nr mumy
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-Loh improve. demolish. or rtpmranY sd.nuLe
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13th
'rinr.toitNsiauuncrosamd isc.nnond"re,
p. _ y rhe pplic'a'for
1, -Sq, FI Floor -Area,, II r „
t�
'Val'uation
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thothesrc xBp .tants tlrepm se, "becomLrmraLeenxlawlenapd,9
fcommenci,g D she Rucmcss Professions Cadcl
thSco.t70011)of .icry and
orThathe is exempt th c's m anthe bei x far Ore allej; li cxempdfdi, Any v olai oi,
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-of Scaion ]031.5 by nn""'can. fore permit suhjdds the applicaei do a civil penalty
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umber
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•'[ Occupancy Type
of am more than Eve hundred douar,($500).,
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❑Les owmar n(the propeny,u my employees with w'eges as Neir sole <ompensesion,
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will do the work. and the structure'is not intended or offered for sale'(Sec. 7044,
Buil.3s'and'Profez,kmn Code: Tic Co..mar, License taw doe. nm apply to an
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'.............. 5.06.'..'....GAS ._. TES'tequired Inspections':. ->' I ...:- .. ._. ... ..._.
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owner of property Who builds or improves Nemon, and wW does such work himxlf
ertb,maghlii,coin entpo,cc,tOo,idadthat,urnip,powarrem,.,aact intended.,
507 - FINAL PLUMBING .
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offend for Tele: if. however. Ne Gilding'or imiumv'ement is imd within one jcir of
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completion, the owncrWilder will have the burden of proving that he did nos build or
improve for purpose of mIc.),
am tofeisi with licensed
❑Loy owner ooje p(Sec.
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7. no Contractor's
instruct the project (gee. ]OLt, Business and Profession. Code:) The Cammcmr'.z
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License Low does nos apply men owner o pmp[ny who builds or improve thereon,
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w th
for such projec¢ wiN a com.aorlp licenxd purse.... the
and Projects
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means Livens
CondrwwrsLicenze Ww.
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❑ l em exempt under Ser. .B&PC formis reason
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Owner
' WORKER'S COMPENSATION DECLARATION '
+ I hereby aff nn undo, MneIty of lierju'ry he of the following declarations:
❑ 1 mve'and will maimuin'a' Cenificare'of Consent to sclGimuie,for Worker's
'
Compensation as provided far by Section 3700 of the LaWf Calc, for the
performance of the work for which this peanut is issued,
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❑ I have and will maintain Worker's Compensation Insmaner. as Lectured by Section
37011 of The Labor Code for the pcdormanca of Ne work for which th„ .it is-
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issued' My W.,kaea Conalmorudn Insurance comer and Pol cY mi b a,.
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Cadic
y1' k 1C.1� t i to '1 E -
l, L,•CERTIFICAnONOFF CM"IONMOMWORKERSy '" ,;
'' COMPENSATION INSURANCE t i
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Thus xctn head mt be completed if the Permit is for one hundred solium
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" Icen fy. Main, he p'I rmnnce of Nc wok forbchdi permn siss d I
shall not mploy'any Person in any ma o as to become subject 10 the Wo k ra
_
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Consauonlaws of C.1domia. Daten�
mpe
.APPliavi.
NOTICE TO APPLICAKI': If, after making this Certificate of Exemption; you should i
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hedome ubje'you mut
shaoins ifde Labor
wthucprvlxo
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.C.od-e,
forthwith cum IY or N pcmtt shall bc dm[d asided.
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"' • CONSTRUCTION LENDING AGENCY
' I hereby affirm that there is a construction lending agency for the performance
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of Iha work for which this permit is issued (Sed. 3097. Civ. C.)„ :....
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QUnder
s Name .. ., ....:
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Lenders Address
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I anify the l have Tad this application and ata thm the aWv<info,mnioLi is
c6med, I agrcc to comply with all city tnd county mduo nee, and stare laws Learing
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do Wilding combustion. and hereby eudioris,eprcunLsives ofthis city TO enter upon,O
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the airwa-mentioned propcny for inspection purposes..
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keep Lamyinshe
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costswayaCodc againstsaid
liabilities. judgmenn. nose and expenses which may in any waypccmc egtinsd said
judgment,
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City in conssqunme of she gmnsing of Nur'ord,.
UNDERSTANDSAND WILL: COMPLY WhlH!ALC�Nr)si NT"
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APPLICANT
Issued by: Date
y
SOURCE REGULATIONS.
Signature.1 ApprrandCoatrarto, . ,., .'., -'Dow -.
- - HAZARDOUS MATERIALf DISCLOSURE
Re -roofs / -
Wll the zpplcad rft m bmlifir, ore.porstrt or handle haamdixo; material
Type of.ROOf %^• -- - - - '. —
asJef ad thydr, CaPerfino Municipal Code. Chapter 9.12. ad the Health andSafety
Code Section 25532(e)
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roofs, shall be Inspected poor to any roofing material being installed.._ „--...._..
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, wllth ppT d' r d Wilding r p d .a rq.f t -, a ice. which
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If a roof is installed without first obtaining an inspection, I agree'to remove
em t hazardous air ronomm ms sed fined by the Bay Ama A 0 tidy Management
"err ' .,% ; . ..
Dist ,
all new materials for inspection. Applicant understands.and will comply with
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non-potht,source regulations..,.
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I have read the hm-'ubmes meieriah requirements under Chapu,l6.95 of the
.,..„all
Califomia Health & Safety Cade, Sections 25505. 25533 and 25534. 1 understand that
if the Wilding does not cmremey have a mnan6 tont id is my Lespnnaibieity m notify she
'occupant of Ne rcquicemend, whicti muni W mho prior doissmnre of a Ciott me of
orrupan<y., ', ;,1 L
Signature of Applicant Date
All roof coverings to be Class "B” or better
Owner or authorized agent Data
,....",,...: _ OFFICE