00120004 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT- CONTRACTOR INFORMATION:
BUILDING ADDRESS: I'ICRMH NO.
7 I Q)L71 121210
OWNER'S NAME: APPLICATION SUIS Exrr
FN TAMES M ONE 'r T /, 'T l ' '/ 2
I PHONE: __ SANITARY NO. CONTROL NO.
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Q ce O ARCHITEC1713NGINEER: BUILDING PERMI I'INFO
C li f%: ELECT PLUMB MECH
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`t S V LICENSED CO,VI'RACI0R'S DECLARATION Job Description
m thun
O Z—a 1 herehy all"rat 1 ain licensed der pm ino
ion, f Chuptnf 9 monomaniac
with Section]mgt of Division 3 of the limine,,and Nofirs.uan,Code,and my licenue
C I,in full brace unit effect.
zo6u i'umccla„ I.it.# REPLACE 40 GALLON GAS WATER, HEATER
>° O w F Date
Contract
to
ARCHITECT'S UECLARAI ION
t ovj 1 undcoend my plan,,hall be..it an public reard,
u S p 2 I,inmsmJ Pnilcsinnal
o nOWNER-RUILOIiR DECLARATION
1 herehy affirm that I inn exempt fmm the Contractor's Liverre Law for the
C Z< following remora.(Section 91131.5.Bu%imes and Professions Code:Any city or county
dm which requite,o Iwrnhit u,con,wd.,,free,inprove,demolish.or repair any structure
Or n
priuoiml,,ar u,. .,no, ire,the applicant im,uelt pclntit m til,usignal,ulmocnt
ca. that he ixlicensed lmr.namit)the movi,ire,xnrline Commences License Law(Chapter 9 Sq. Ft. Floor Area Valuation
marnmewing with Section 7")of Division 3 of the Hudde.and Pram,vion,Code)
r that he is csmhpt therefrom and the havi,for the alleged corruption.Any violation —re
A Seen 701 1.5 by any applicant Gra a pamon wtecel,the applicant In a ,,it Imrmlty,
ret an(more(hath Ewe hmndred della,,($sten. A PN Number Occupancy Type
❑1,as owner of the propcny,car my employee,ream wage,a,their mile compensation.
will do the work,and the sumemroffered
e i,not intended or lot Ole(Sec.7(W. - '
00
thlxine„and prare,.imr,Code:The Comann ',i.w."m Law doe,mot apply In an Required Inspections
,,.act ofpngxn,Who bulhk or improve,Ihemon,and who does inch work Ii ulf
or through his Own employee,.provided that such impmvement.s are not imonded of 502 — FINAL PLUMPING ENERGY
latest for sale.If,however,the building ar impnoianent i,mild within one year of
hcompletion,the owner-builder will have the harden of proving that he did not build or 506 — GAS TEST
tprove for.,.mattof,mea.
❑1.a,ownerifthe pmpany.rateselm,melyenrader 6 „mrcensedlammemr,tn SD7 — FINAL PLUMBING
,Rua the project(See.7(w.ownrBusiness and any who
Gdc:)The Continuumthrams
Liame Law does no apply m an owner of propcny who) roc or Improves lhc,, he
Cod who contracts,Licfor such pryede wish a avnmctnr(xI liccn,wd punuam In the
01 am exempt
Licunde Luw. /
❑I am exenhp(under Sec. .N k P C for this reason
Owner.Dale
WORKI?R'S COM PIiNSA'I'[ON IIIiChARAI'ION r
I hereby affirm under tonally ,I perjury one of the following declaration,
❑ 1 have and will n mmhin a Certificate of Consent to elf-invom for Worker', v
Cmupemxaion, :s provided for by Section 3700 of the labor Cade, for (he
per!mmuce of the wok for which Thi,permit is i„Bed.
❑1 have and will maintain Worker's Con,pemation Inwmnuc,as required by Section
3710 of the labor Cale,torr(hes ps,douncince of the work for which this hermit is
sued My Wader',C( von,aion In,urun c currier and Pole,number are: -
Cra fee Policy Nu:
CERTIFICATION OF 6CEMP ON FROM WORKERS'
COMPENSAnON INSURANCE
T his Oction need not he emol)[cled if the Iwo nit is for one hundred doll—
IS I(10)orless.)
1 uceify that in the performance of the work for which this permit i,issvlid,I
,hall nut employ any Iturxm,In any manner so e,Io become,uhjccl 6,the Woken.'
C.....Ili nn law,of Calllornia.Uta,
Apphcam
Not ICE TO APPLICANT:If,a0er making this Certificate of Eaatption,you should
become subject it)the Worker s Coupenmtlon provisions of the limits,Code.ynu mus(
Q O Forthwith comply with such provisions or this permit shall be dean ed revokal.
FCONSTRUCTION LENDING AGENCY .
a ' I hereby M.that(hem i,it conurvon..lending agency for the Pero rnm nce
RlA of the work for which this permit i,issued(Sec.3197.Civ.C.)If. Londe”,Nmnc
7 z Lender'.,Adams,
V Q 1 certify that I have read this application and Mme that(he above information is
k6 F. Bonnet.1 agree to comply with all city and county ordinance,amt slate laws relming
Q V m build....m...u-nn,and hmrchynutI non m,ramntntivc,of this city,,crime upon -
ythe above.Imananned pn,pmety f......pmok n Por,osas.
(Wel agree to unc.indemnify and keep harmless the City of Cu(nnino against
rn habit itics,judgments,costs and expmmse,which may in any way raceme against,aid
U Z City in canon mocc of the granting of this permit.
APPLICAN'1'UNDEIts I'ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
Signature ofA,licanUCoomis, Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will tla,al,li't iar mom htdld'mgneenp:an,orear hitnnle haumdat,maw.al Type ofRoof
:is delimit by the Cupertino Municipal Code,Charter 9.12,and the Hcullh:rod Safety
Code.SectioOYcsn Ls532Wf! 0 N
All roofs shall be inspected prior to any rooting material being installed.
Wdllheapplicaa... mare,building nccnlrama,aegnipmeoardeviou,which If a(roof is installed without first obtaining an inspection, I agree to remove
mount hmanloo,air coula ninam,as lur m d by the Bay Area Au Quality Man agamcnt
• Dotrlc(p all new materials for inspection. Applicant understands and will comply with
0W, ON. all non-point source regulations.
I have Icall me haaarda nnacrids o aim:ncan under Chapter 695 of the
California I ieanh&Sam,Coda Suctions 25515.25513 and 25531.I tudemtlud that
if the building does of curmatly base it maim,that it n ony m,,,n,ihility it noify the
occupant of the requirements which mus(be met prior to i,nuemce Of it Cenihcate of
Occupancy.
Signature of Applicant Date
Owner of euthormed agent Dat. All roof coverings to be Class "B" or better
OFFICE