00090153 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: '
(BUILDING ADDRESS PERMIT Nor
OW'NER'S NAML APVI.ICAI'KIN SUB ANTE
00090153
ifis IONS: 1484 SHANNON CT SANITARY NO. CONTROL NO.
/25/2000
Q O O ARCBITECDI:.GI ": BUILDING PERMIT(• 0
F
L�IV JOSEPH T RND LINA BLDG LECT 14,UNMECH
IJ
azm IJ I. CI
LICENSED CONTRACTOR'S DECLARA'ION Job Description
Z O m 1 numb,utfum thnt I am licensed under Wovisiom of Chaper 9 commencing
0 wilhs"'Ind 7kXBol Divisioa3ulh,Busines,r I Hole,,knaCode.l lon,Ikons
6m5� in in full face an Yccl, eee111
z 6 I.irenw CJ;I. 6:a,_ Contract...r
AHCt{I"Il!CI"S DECLARATION
1 anmraww ratty plan,xnau Ire dam as pubue resntdx
cis, REPLACE 50 GALLON GAS WATER HEATER
c LL I.icen,ed I'rofeaional
o OWNER-BUILDER DECLARATION
1 thereby affirm that I ant exempt mal the Contractors Livens Law for the
F 4z a fallowing mr,on.(Section 7031.5,(Toxins and Prum,sions Code Any mit,ur anunty
5 F o which requires a pemtil to ca struct,alter.improve,demolish fistructure
r repair any
a Prior to its issuance.also requires the applicant for uch permit to file a signed statement
that he.,licmtwd parxuunt m the pnot slnn,of the Comment,',Limma Law(Chapw 9 Sq. Ft. Floor Area Valuation
Icon ting with Seen un 7011@ or Ulvkian 9 ol'Ihe Buslne,s and P...I...ions Codd
or that he ix exnnpt therefrom and the basis for the allege)exemption.Any violation
of Section 7011.5 by any applicant for u permit subjects the applicant m a civil penalty
,if not mom had five hundred dolhus($510). APN Number Occupancy Type
❑I,w owns til the pmpaty.or my engnoycex with wages m that sole tnnptcnsaljnn, 1264
will Jo the work,and the slmcmre is not intended or offered for.ale(Sec.7044,
Business and Professions Cade:The Conuatur's License Law does not apply ut an Required Inspections
r of pmpeny Who build,or improve,Ihemes an,and who dosuch work himself
,thmagh his own emo.pmycpnoulw Yu
mat ,,in improve cut,are trot Intended.,r 36202018- 00
ofi'cred Int arae,if,nor,tire e building , nlpm Int is.nld will,in 0 e Year
of
completion,the owner-hnilder will have the burden of proving that he did not build or
improve for purpose of sale.y
M 1.an nwmr of to,propwt,.all exewaivcly<nmrnenng still r«n,w euntmnmx t„ 502 — FINAL PLUMBING ENERGY
m.stmct the project(Sec.7844,llusinc,s and Prolc,smro Code,)The Contrecmr'.s 505 — GAS TEST
License Uw'docs nm apply to an owner of prot,nrty who builds or impmve,thereon,
and who commeta for such pmjceu.with a contortions)licensed pursuant to IT 507 — FINAL PLUMBING
cnntoccou,l.iecnae I.av,
D I am exeloltt ander see. .B i,P C tot aria reuxmt
Owvur Dam
WORKER'S COMPENSATION DECLARAION
1 hereby off mi under penally of pe9ury out al tile following
dalunttions.
J 1 have and will maintain a Certificate of Consent to aclf-insure for W'orker's Q
Contpenanion, as provided for by Section 37W of the Labor Codes for the 1�5
Itrfivmmcc of Iho work for which Nis permit iv i.s,ncil
❑1 have and will notation Workers Compenution Insurance,as required by Section
J7W of the Labor Cole,far the serformema,of the work fur which this pump is
ued.My1�W,�ossrk,,,e,.ra,,,C,omps�e^rssation Insurance sorrier
raaannd Policy-number are; -
nic,CtsCr[rc VtbQ!X policy No,
CERTIFICAI ION 01:EXEMNION FROM WORKERS'
COMPENSATION INSURANCE
(Tins section v,,d not be oriplided it lie pe....it is fur ane hundred dollars
($110)or 1cs:J
1 certify that In the performance of the work for which this permit is issunl.1
,all ern employ airy Isom..In nay nmtinn on a,to become une.or she Worlaco' -
Compement I,dws tilcilifomio.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenifiam of Exemption,you should
b¢snne object 1,the Wnrkle,Cnmpenwfion Prov s ,mof the Labor Cath,you umst
OI'nnhwlth comply with ouch prnvi,ininx fir this permit,hull he darned revoked.
Z V1 CONSTRUCT ION LENDING AGENCY
? 1 hereby at6ma that them in a construction lending agency for the performance
of the work Ibr which this permit is issued(See.3017.Civ.C.)
lender',Ni the
= z Lender's Address
V 1 cenify that 1 hmc read this application and state that the above information is
W cnn'ea.I npure to tangly with all city and county ordlnatmes and stile laws relining -
[) Io buildol,,umuraction,and hereby tmthe...c mprnwsnoaves of lhiwhy m enter upon
the abrwomentioned property for insp ection pur nal,
(%Vc)agree to save.indemnify and keep hamdess the City of Cupertino agmina
U. liabilities,judgments,cn.s and cxperwes which lady in any way uecrc against said
C, City in ennwyuuncc ul'the grunnngr(atia lennil.
APPLIC NT UNDERSTAND �y WILLC MPLY WITH ALL NON POINT Issned by: Date
U 10 S., or
ocof Applica I/Conimnor _ - - [)aid Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future hall I.Trant stns nr handle namdom nolle ail Type of Roof
as defined by the Cuperdna Municipal Code.C'h rpmf 9.13.and the Health and Safety
Code.Sallam 25512od?
o Ye, ❑No All roofs shall be inspected prior to any rooting material being installed.
Will the appfiemnarfuture building awcepamaxeewirvnentmdevice,which If a roof is installed without first obtaining an inspection, I agree to remove
noir hazardous air connotations as defined by the Bay Area Air Quality Management
[)laden all new materials for inspection. Applicant understands and will comply with
❑Yes E3 No all non-point source regulations. -
I Imve read she ha,adou,noderials recommend,under Chapter 695 of the
Cali Roma realh dr Suf.,Cwe,Sections 25505.25511 and 25574.1 understand that ///� _
1 l the In illi ag does not currently have a mnont.that it is my re,ponsibi fity to nodi fy the //fie
cupant of at tequi mens which n , ba act pr' n iswanu til n Ccn'dio:uc of I
Occupancy' A�dgnatme of Applicant Date
r nnamai�w Geentt _z� All roof coverings to be Class`B•'or better
OFFICE