01120044 (2) CITY OF CUPERTINO
]BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUu2D110:�§RE'ftRRACE DR WATER HEATERS ONLY PERMnNO. 01120044
fsrf@A'TgJM DONALD K AND MARGARE `f�
970 E. MAIN ST, SUITE 2 P1L�2'7T y`2n1
S"ONE' (415) 566-2209 SANITARY NO. CONTROL NO
a re c ARCHITEC'ENGINEER: BUILDING PERMn'INFO
Ic
te- BLDG ELECT PLUMB MECH
F i��'
Z LICENSED CONTRACTOR'S DECLARATION ti
iz=o Ihacby affir.n that l am licensed under provisions of Chapter 9(commencing REPLACE 50 GALMP 6H WATER HEATER
;ms-J wits Section 7000)of Division 3o1 he Business and Pofroiom core.and my license
is in full force ana�(r.
sa License Cla]y� +/�'�-r Lic.a
i 3 a y Dom�y7�i7�' Contraf
ARCHITECT'S DECLAR TION
vS 1 undrmmnd my pians shall be used as puhlie acmes
i cp z Licensed Professional
u.
OWNER-BUILDER DECLARATION FINAL
�®
u = I herehy affirm rbar 1 fon countrom fthe Conm¢u+r'x License Law for the 0 v
following reason.(Section 7031.5.Business and Professions Code Any city or county $700
E x O which requires a permit to construct,alter,improve,demolish,or repair any armature
i3m prior to its issuance.also requires the applicum for.such permit m rile a signed statement - --
bathe Is licensed pursuant to the piano mus of the Comment's License Law(Chapter 9 Valuation
(commencing with Section 7")of Division 3 of the Business and Professions Coal `
.,,but he is exempt therefrom and me basis forma ullejed exemption,Any viola, o -
-of Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penalty
nfmc momman we hurded dapars($5o0).mplvpQ�[ L PLUMBI G ENERGY)ccupancy Type
❑Las owner of me property.or my coycsdi
earirh wages as their vole an,inmion 506 - li TEST
wBusiness and Professions Code:ill do the work,and the structure is not Intended or offered for sale(See.]Q4q, ,
The Contractor's License Law dons not apply m an pectlon5
owner of pom eny Who builds or improves mr.eon,cad who does such work himself
or through his own employees,provided(but such improvements are not intended or _
offered for sale.If,however,the bottom - t is sold within one Y - - - - - - - -- - -- - -
gorimen of pro Ycldo )
completion,the ownerbale.),will have the burden of proving that he did not build or
improve for purpose of sole.).
°L as net nfthe . .n a -.
grope y,am Bromevely contracting with licensed Contractor
to
,. License
construct the project(Sec.]0i q,Business and ,AyProwho
Code'.)The improves
de m n. _
License law toes not apply man owner of progeny who builds s prion s thereon,
and-who,a License
L such projects with n commaor(x)licensed pursuant to the _ .. . .. ". ._ .... .. ". . . ._". _. -
Cnmranor's License law.
°1 am exempt under Sec. .B Ni P C for this rayon +'
:.
Owner
wncr Data
WORKER'S COMPENSATION DECLARATION
I hereby affirmunder penalty of perjury one of the following dwlarmlons
:. � I have and will maintain a Candidate of Consent to self-insure for Workers
-!q•� Compensation, as provided for by Section 37W of the Labor Code, I'or the
performance of the work for which this permit is issued.
A"0 haveand will maintain Worker's Compensation Insurance,as required by Section
0 or the Labor Code,for the performance of the work for which this permit is
`1dm'
issued.My .'s Coumpenwiint��/Imne
umr carrier and Pulu,nm'ub`er are
Cam/r� 3�G •0..r++�f.�t Policy
"GERI'II'IGATIDN OF E%EMFTION(BOM WORKERS:' "
.... .._ .,. COMPENSATION INSURANCE:.• .. .. __._"_.__.__,.-.__.____-._..__�_._. ....____._....._.._.._._.___ _.._..__,........ .
(This inion need not be annpleteJ if me permit is for one hundred doll...
(Slfq)or lns.j '
1 certify roar in he perfotmnnae ulthe work for which this penuit is I....d;I '
shall nor employ any person in any manner so as to become subject to the Workers'
Cnmpensmien Laws of Cu1'doomai Date
-Applicant .. . . .... _. ." _ -' ".... .
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
G O fordo ith cote 1 o hat suchu s C s or this rmi,shall be deemed revoked u must
,l pensa p,,osumau
- EN Y .�
pyx, provmsion pe
CONSTRUethemis donshoION ENDING AGENCY
I herebyaffirm that mere is a conmmamn lendingagency for rhe rfotmance
of me work fur which this permit is issued IScc 3(19],Civ.C.)
Q -Lender'v Name... ,. . .. ... ..
^D Lender's Address
1 amity that I have read ria application and state that the above information is
W E.. amm'd.I agree to comply with all city and county ordinances and state laws relating
O,[) to building inuromelion.andhereby authorize representativesftti. ityt ter upon
for alawc-mentioned progeny for inspectionpurposes.
(see) indemnifyand L ep Intense, he City ofCpen spans,
V]
liabilities.judgmenuo costs J expenses which may in any way accrue against said
U Z City inc nequ eof iffe Ittionfin,offoss'non.
APP((CAST REGULATION
MILL CO LY WITH ALL`.O POI .T Issued by: r Date
SOURCE kEGULATI xCium /L j ate
Signature of Applicant/` RDOor Date Re-roofs
IIAZARDOU MATERIALS DISCLOSURE '
- W511 the applicant or future Municipal
o occupant stere 1.andthandle harmonious material Type of Roof - -as defined by the Cupertino Municipal Cotle.Chapter 9.L1.and the Health and Safety _
Code,Section 25532(x)' -
°i'°a ' rte`° - _ All,roofs-shall be..inspected.prior to any roofing material being installed.
Will the pplca t or future Wilding occupant use cgopmentm devices which If a roof is installed without first obtaining an inspection,'( agree to remove
n hazardous f y d d by she Bay Area Air Quality Management
DU.u' r all new_materials for inspection. Applicant understands and will comply with
ml( he I all non point source regulations..,
`_Y 1 have read tSafetyInvode, mann 2 505.mmaire 533 amm,under 4.1 mideratand 695 0(the
ifthemil Health Safety Code.Sectionstenan509at it
and2553q.1itytontif that
if the building does not densly have a must
be i al ice is my responsibility to idi"e the
occupant of rhe requirements which must be and poor to issuance m u CenlGeme of
Co`mpan`ySignature of Applicant Date
/' ///O)
gent um All roof coverings [o be Class "B" or better
Owner or authorized... .. _ OFFICE