01020136 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
BLOSSOM DR HOT WATER INC 01.0201.36
OWNER'S NAME: APPLICATION SIM DATE
2531 GRRCELAND AVE 02/28/2001,
41 PHONE SANITARY NO. CONTROL NO,
(E50) 298-8494
❑C Z ARCHIIF.CI'7FNUINEER: BUILDING PHRMII INFO
Op
w_ BLDG ELECT PLUMB MF,CH
UG
l4 y
S y n LICENSED CONTRAC OR's DECLARATION Job Description
ZO _, I hereby affirm that 1 am licensed under portof cm,of Chapter v kom uscru g
F,�t J with Seetinn 7(XX)I of DivisianJo(IIu:Business and Profession,Cale,amt my license
ays� is intell force unit otkot.
Liccnsc Claax Lic.X REPLACE WATER HEATER
s K 2
Sa O Dare Comracmr
W 3 u.t4 AkCHI'1'f;Cr'S DECLARATION
C�0, 1 codersend my Fam"ball ria mod us Pathe team..
un)es C�O Licensed Prolwsional
ed`o OWNER-BUILDER DF.CIARATION
1 hereby affirm that 1 am Isom,from the Contractor's License Law for the
following reason.(Section 70315.Business and Profs— me.Core:Any city or county
i s❑ which requires a forced to construct,alter,fropeo ,demolish or repair any strucme,
ouprionwasL y Ili p['I' t( h.o. 'u 11 g J.rt tool
a. rt he is loccused. . t to the provisiors ofll ConbaclAri1 (Chapter 9 Sq. Ft. Floor Area - Valuation
mon,tt„g ag w'In Scott„ 7000)(If U.....a3r tl,,Banh
as,test' d lrtsxtn.Civil) $5��
m that he isorient l therefrom and the basis fill the alleged exemption.Any violation
of Section 70315 by any...Ecom fill a Itvair,subjects Inc opplimal ,,a civil pcnahy
of nm tuom,han five hundred dollars(s50), A PN Number Occupancy Type
C 1.as owner of the pmpcny,or my employees with wages a,their sole compensation. 00
will di the work,and the swcmre is not Intended or iWSd Ea side(Sec.7044.
bovines,ted pmt..inns Cade:ntaCumm,00',License Law m»•s test aprdy m an Required Inspections
r of pngtcny Who builds ua r...,,oves therein.and who does such work himself
(itnwtt° provided 502 — FINAL PLUMBING ENERGY
f through his awn empk c den Ilial xuch vememeuwes within
not intended or
offered for tele It.however, l have t or indenof paving
n sold wllhdd nee you of
Tri.mpkdnm me own.ennuime will have doe nnrtlan nr proving tom ne did ria bnua or 506 — GAS TEST
p for parlso,c of )
507 — FINAL PLU GING
con f tm.p .en 1 lye t act i with l Jcollector m
theProject(a ]toil li J Professions C x ) op Contract...s
lone L I t'.plyl tp (tour M1 hdldl�
ec p tb 'h
and h t is ti ash pr9uts will a nruuor(s) al plc u t to the r�
UI,r Io.',Licor,r,l,:w /
C I um exempt under So,. .B N I C for this novo
((wool IAS 6/
WORKER COMPENSATION DECLARATION
I hereby Minn under penally of perjury one of the following declaration:
\: ❑ 1 have and ,If maintain a Ceniheute ext Conmm m x,Ibima c for Work,,,
Contpcmwinn, as pi,,afd for by Scullin 3700 illit,, Labor Colo, fur the
performance ul liework lin which Ihi,permit is issued.
C I have and will trial nein x'orker's Cmnpensm ion Insurance.as required by Schon --—
3700 of the Lubin Cndo.for the Ito fordarom of the work for which this permit is
Swed.My Workers,Compensation Insurance carrier and Policy number am:
Carrier. Put icy No.:
CERT I4CATION OF U HMITLON FROM WORKERS' I O�D "�
COMPHNSIOiON INSURANCE ` VVV
(This fall....food nm be completed Hill,permit is Lor one hmWrtal dollars
(M W)ar loss.)
1 comity that the pert f the wark for.wadothis porrind is issued.I
shall nor employ any person any courater*9 as t becounic.strinject t the Workers
Conc. I .CaliforniaDt
Applicant
Nickne h,clAPPLICANT r II 'k' illi o, (I sI fl I ' You u hold
Ween hjsq to the K k L l+ ,tl , real
shis all l 11 I h ( J Y re q
-Q Q fonbwnbcmnply with msh.nnasionx or dna penult,hall he detailed tn'okcJ.
Z CONSTRUCTION LENDING AGENCY
I hereby alien that them iso Con.ameion lending agency for the performance
of the walk far which this permit is issued(Sec.3097.Co.C.)
L Q l.endcr's Name
_ Lchaer's Address
(..) 1 cen0y Thal I Love rare thin k,pli,aIi un I"am the the ahwc of uslion i.
ks [� co rtrcl.1 agree Io comply with Ill city I I county ordinances and sure,laws relating
C V mbuildiagconmmein r.and hereby amhorire repteseriativnnf this co, ,,enter upin
} ryt the aMve-mentioned pmpcny for inspection pw.ows.
L (We) me lnsavc.habitually and keep harmless the Cdyof Cupeninoagainst
(4 liabilities,ju lgoicare,costs and expenses which may in any way accan against said
C.7 Z City in consequence ill the granting of this.moil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS. y'
Sigadhom of Appl,adVCnnlrI,hr Datil Re-roofs
HA'LIRDOUS MATERIALS DISCLOSURE
Will the a.phaam or future building woupanl mote orliaalle hwardous drakrial Type of Roof
as defined by the Cupertino Municipal Cork.Chapter 9.12,and the Health and Safely
Calc.Section 255320)”
o Yaa ❑Nn All roofs shall be inspected prior to any roofing material being installed.
Will nteappicaIa alott.rent.utmtgneenlnmtuse egnip.oe.tlor devices which If a roof is installed without first obtaining an inspection, I agree to remove
�^vil bumriluus cit cuuwtrimmts a,daflncd by me Ray Au Air Quality Manage oil
�ItricV. Yc, ❑N;, all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have mad the harauJuus notenida requirements under Chapter 6.95 of the
California Ill R Safety Cale Seoul,.%25505.25533 and 25534.1 unde....d that
.t the building dove's not currently have a tenant,that it is myuspon,ibility to notify the
occupant of the regni mments which.nuc be met prior u,is,nunce if a Cer ilicam of
Occupancy. I t ature of Applicant Date
Owner I,, maw d.glm Date All roof coverings to be Class "B" or better
OFFICE