01040102 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PIiRMI'I NO.
190 STAFFORD OR HOT WATER TNr rA 1 02
OWNIiR'S NAME: APPLICATION SUIT DATE
1
• PHONE: SANI'T'ARY NO. CONTROL NO.
❑ Z ARCIII'I'ECT/LNGINT:ER; BUILDING PERMIT INFO
El ELECT PLUMB MECH
1= IJLIC
I hereby affirm thtlI am licensed undn�urialonslof ChapAI ter 4(commencin8 Job DesClTpl1D0
F`^C. whin SerG"n 7001)10 D vieiinl 30 it,llp,ine,s trod Prufexxionx Carl my liccmc
a'i, Ic in fun lime and elrecl.
a,tie I:irpn.eclass ut." REPLACE WATER HEATER.
3 a. Dae Convert
ARCHI'IECr'S DECLARATION
O 1 unde,dand my plan,shall report m public record.,
to
Linnad Profcwinnul
x da,I ant snaLDEH m the ARm'ION
I Mreby.(lien That I nm exempt rrnm the Cont(....Co An,r Law lin the
Z a which ire mnenn.(Section cumhh,%tinesc and I'rofes,iom Code Any city nr ,,am
a,€O
which t it,Les a permit ns int,Isea,alley,improve,demolish,nr repair any ter coy
µat Sri that hnibiswmru.ulnait In thuhcnppliS(If In,Contractor,
Limemre e La.(tamnmm
(conci,ramedppnaaolrotocent.D,Wop3ol the mrmrasand.elfew(nsCodv Sq. Ft. Floor Area Valuation
(r, Ing web Shane)01X0 ter Div o 10l the l,i e,;ad Pnirc.,s endo)
or mm he 7 31.1 b 1I y ap di and he basis far(he eb,hp, ..w.alon,Any solution
of Sec(iun 7031 5 by any dred doll for a permit wblvas the aPPlicunt n)a civil pcamby - -
nnmldinmmanEventndmdanlhnlssl«n. APN Number Occupancy YPe
Ell.m owner of roe prnl,eny.or toy employes.w.11,wagm ae their,mc compcmtnion,
will do the work.and the,,pours i,not intended or offered for sale bcec 7111%.
Busier and Pae
rf„ion 'r
,Codc: oe Comn¢mLaw r's Lhenw der,nor am pply an ., equired Inspections
owner of property Who builds or intprtnes Ihcmon,and who does such work litoodf
), pa din m ,awn<a„pin>ee,.promded that such impmvemenas am not intended or 5oc — FINAL PLUMBING ENERGY
oneral for sale.If.however.the budding or imprnmiment is,old within ono yrur of
completion,the owner.bnuder w;nh:t.e the burden of pouting that he did not wild or 506 — GAS TEST
prove Tor purpura mr stdc).
❑1,as nwm'r onhc prnpeoy. ,t c.dhooi,cly contracting with licensed conamcon,to 507 — FINAL PLUMBING
a,muum the pmjec,(Sec.71X4,basins%,and Wofc,00an Cade:)The Conamc(or,
License Law docs not apply man owner of property who build,or improves thereon,
and who contirwo,for.such pmjecu with a enntraaons)licensed pmnumn e,the
Comoctor,Lireme Law.
filum cncmPl antsy Su', .❑k PCtor this atx,nn
Ow'ncr ENc
WORKER'S COMPENSATION Il[CLAHAIION �e
I hemtV affirm under penalty of perjury one rf the following dedumaion, MAY 0 4 q 2001
•r O I have and will nrinmin a Ceridieam of Concent to wlot r Worker',
Compens tion, a provided for by Section 3700 n1 (he LaMm Code, rnr the I�'
pal"rtttanre of the work ho,which dti,I....it is,xened. BUILDING
01 nave:md Will,lt.tim:dtt Worker's Cmnrenaation Insurance.as reyaired by Section G
3710 of me laver Code,for he perlLrmancc ol''he Work to which this Penni(ix
sued,III Worker,Compensation Imuonce can ier and Policy number am:
Camey. Policy No.:
CUR I'IPICA'I'ION OP E)(13MITON I71OM WORKERS'
COMPENSATION INSURANCE
(This.action need not be completed it the lenni('n Inc ane hundred dollar, ,
1511X0 nr less I
1 cejdy that in the performance of be work for which uric Krapi(is issued.I
shall nal employ any...on in any nwmuv,u u, ,,M1cmme,object n,the W..kc,'
Componmtion Lw,of C.1iflrrnie.Dale
A,h,i nI
NO[ICH TO APPLICANT':IL ants ne kin,Thi,Ccnifilam nl Exemption,you should
hecome.atbjeca m the Wnrma',Compcnxution Powi kms of he"No Calle,you mm,
t�Q O romhwltb 1panply.(,It ac It pruvisiotis at thi,pettnh shall he deemed rooked.
F .yN.o CONST RUCTION LENDING AGENCY
FCI herehy affirm dut drem is a coca nau dr lending agency for the permcc
fo ,an
of the work fir,which mix pcnna Is isoard(Sec.1097.Civ.C.)
❑ render',Nano
5 z Lender',Addre,,
C.1 0 Iredify,hal i W. cad(hi,applicmi"n and e,am that the uNoc infomalinn i,
F.. mnttl,i at m unnply with idl oily amt manly n dinanee,and dam law,chain,
Q I, toWilding c(comelinn,and hereby authorise cFmsenmtive,of this city to enter upon
the ah"m-mmiptioncxl pmparty da inspection purpsoc,
F y We)agme a,stve.indemnify and keep lamlexs the City or Cupertino agaitta
rn Iinhilitie,judgments,costs and c,lemm which may in any way tware agnea said
V 7_ City in eomeyaenec or the ammh,nr ode I,cnotil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POLYP Issued . Date
SOURCE REGULATIONS. Y'
Sigmtmmml Appli,adA::,mmwlm Ilam Re-roofs
HA9.ARDOUS MXIERIAl S DISCLOSURE
Will applicantor future Wilding Iteupan(lore nr hurdle wzallor,material Type of Roof
as defined by the Cr,cnlno Municipal Co,1r.Chapter 9.12,and the Wallb and Surly
Code.Section 255320)7
O Ye., °Ni' All root's shall be inspected prior to any roofing material being installed.
Will tw:y,pfradorform building occuprmuse etepn'entordewce,which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamNouc air coordinators m defined by the Bay Area Air Quality Manugetcad
nco all new materials for inspection. Applicant understands and will comply with
Cl Ye, 0N" all non-point source regulations.
have trod the hazarSafety
Cade.
eedo alx 505.25nenlu under 4.1 un a 95 0l the
it he mil Health N Softly 6dt.Sacla m 255115an it
all 833%,I understand that
(Viarbuildingdue,uirmneinlyhaveatnmm,tint ii is myssuance Hila earamify the
nccupam of the myuiremenle which mol W Bel prier to issuance ol'a Crrilicme ul
D"xpr"ry' Signature of Applicant Date
ownei.I,,r.l1r)ri,edr,tnt Date All roof coverings to be Class "B”or better
OFFICE