01030051 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS, , PERMIT NO.
10903 SWEET OAK ST CARREN TIMM 01030051.
OW'NER'S NAME. APPLICATION SUB OAT 1:
CGRREN TIMM 03/09/2001 '
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PHONE: SANITARY NO. CONTROL.NO.
❑mZ ARCH['I,',CI'lIiNGINIiIiR: BUILDING PERM n'INFO
W 0—F O BLDG ELECI11.UMB MECII
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IJ LJ
yL LICENSED CONI RAC OR'S DECLARATION Job Description
oy= I hereby affirm that 1 am licensed under Provisions of Chapter 9 m hair min,
m 1—ce with Secinor 7000)nfl)mision3 al the Busim%s and Aaficviots Coda and my license
ca is in full force a adeff«t. INSTALL NEW WATER HEATER
z a License Class Lic.x
i O Date Commaor
vl ARCHITECT'S DECLARATION
Cµy'1 g 1 maceration]cry plans shall Is,used as public mcori
ad6h 6 p O LiccmcJ 1'rnle.,zinnal
ci OWNER-BUILDER DECLARATION
2 m I hereby nllirm thio I;a crop,floor the Cnntrtcmr'e Lioeme law tort the -
tY'R followingrenson.(Section 703 3.5.Busincm amt Profession Code:Any city or county
5❑ which tnryitae a front I,,Inn rucl.alter,iniptnvu,deo aINIn,or repair any structure
ism Prior to its issuance,aim)requires the applicant lin such permit to life v signed statement
that he is licensed fato,ormI 'be powsian.ofthe cnntmnnra.icenseLaw(Chapter if Sy. Ft. Floor Area Valuation
(cmmnmncinF with Sectio 11X10)of Division 3 of the Business and Profession.,Code) $1
acref
,that he is exempt thnvn and the basis for the alleged comideinn.Any violation
of Section 70315 by any applicant foal a pari',subjects',he app(leant h,u civil Irtnully
"foot form than five hundred dollars 0500), APN Number Occupancy Type
171.us owner of the propene or my employee withegcs was their sole compenmrnn. 42 00
will If, be wore.left Etc sn u,n m is ren intonded o,offend for .In N,c.1144.
Business and Prolcssions Code:The Contractor's License law Joe,not apply w an Required Inspections
orr of property Who builds ur in.provus thereon,mrd who docs ouch work himself
through his own employees provided that.such improvements are not intended or 502- — FINAL PLUMBING ENERGY
offered I„sada.If.however,the building nr Improvement is sold within are rear of
n.opmdon,the u,na.Rudder,will have tete b"nett of pmnin,that he and trot mild nr 506 — GAS TESL
limit iicfortmovec1f`a'e''' 507 — FINAL PLUMBING
❑1,as owner of the property.ant exclusively contracting with licensed contractor to
,lono,t the p,,,W(See.1041.Ifimiocns:rod paid..slons C,aL:)Tac Contractors
License Law does not apply In an owner of preperty vital Wild%or improves',hereon,
hind who cannier,for suclr projects win,a umaacmrfs)scene i Pasoan', I,the
commences Livens,Law.
❑1 all ac pt undo,Sec. .If A 1'C lire this reason
Owner Dam FINALED
WORKER'S COMPINSXI ION DECIARAT ION
I hereby alfinit under penaey of perj,lry ane of f Ilewing declarations MAY 17 2001
❑ 1 have and will nrainfall,t Ccnillcam rel'C'n I,,.n lu mll�ivun I'nr Worker's
Compensation, as provided lire by Section TRIO of the LMrt Cede. for the
E,d mane,ofthe sem,fns which thio pcnail is issued.
ID I have and will rtmin.ain Worker,Coonla Erman Invnaah,as re,I"ircd by lection BUILDING
371()of me"We Code,tort the priori of the work Iia which this permil is
is I,M ink 's C'nt p 'nn I.tavnncc carr error (icy am ram:
Carrier. IIF :X(icy No.: � S
CIiRTIP1cAno, )ft iXEM19'ION FROM WORKIiRS'
COMP...'A'I'ION INSURANCE
fl'bis mention need not be completed if the permil is for one hundred dollars
(5100)or Iron.)
I certify that in the perfeiri of the work for which this perrea Is issued.1
shall not employ any pezm in any numi sat as to Moms subject to the Workers
Camgmnwtion Laws of Culifnmin.Dole
Applicant
NO,'ICE'10 APPLICANT:If,a0cr making this Certificate of Exemption you should
hecome avbjea to the Wi nker's Compensation provisions or'he labor Calc.you card
O O Ibnhwid,rcri—do...h provision nr Elis permit a hall be deemed revoked.
C'ONS'FRIJCFIQN LENDING AGENCY
a > I hcreny ufrrm Eta(them Is a emm�ucdon lending agency far the pertbmtanee
W of the work far vi',his permit is i..ued(Sce.3097.Cie C.)
y p Lender's Name
5 7 Lender's AJdl
U 0 I ccnify thin l have mad this application and same that the above information is
fa+ tr c,lime',.I agree..,...reply wltlt all city and eoumara
y onlmes and e,,,a Tawe miming
O U to holding construction,amt hereby authorize reprewmmi",or III,city a,em c,upon
Lit the aMwolemotloned property for in,oction purposes. -
�" 0. (We)agmc 1. oc.indemnify and keep lane the City of Cupertino agents,
lin liohilities,judgments.coon and expenses which may in any way occme"gains.wit
U Z Cry in n.nwyuence of the 6running or this permit.
AI'1'LIrf}}INTUNDERSr NDS. N WILI'COMPLY WITH ALL NON-POINT Issued b (. "� Date
SO�yC'Ii RF ULA,. 3 _,q�/ y'
,Igl.amre afnppbeam 'antmc,m D:m Re-roofs
ZA
HARDOUS FRIAIS DISCLOSURE
win me apprcam or Etatrn bre ding elaonant prom o,handl,millibars material Type of Roof
as defined by the Cupertino Municipal Cala Cbapmr 9.12 and the Heath and Safety
Cade,Section 25532()!
0 ye, ClNo All roofs shall be'inspected prior to any roofing material being installed.
Will the appfcamatWarm building..Pa.,no,e,lumn.amordevice,abild, If a roof is installed without first obtaining an inspection, 1 agree to remove
emit haeallous air conforil as defend by the B.,Area Air Quality Management
Districe all new materials for inspection. Applicant understands and will comply with
0 Yen 0N" all non-point source regulations.
I have mad the hazardous mnteriah requirements under Chapter 6.95 of the '
CrEfontiu Hetdth N Salrty Cade.Sectnn,25505.2553)and 25534.I undarounJ',ha,
if the building does not currently have a mount.that it is my resp,nuibility,In notify the
ecupunt of the mgm.mm 11 wh'I Intal m,sect prior to issuance of a Cnrtifcum of
°CvYSignature of Applicant Date
3--q--01
segs
wnerl,ra..theri...I.,c t Date All roof coverings to be Class"B" or better
OFFICE