01040028 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
IIE51 TIMBER SPRING T. WATER HEATERS' & MORE PL13G. 01.040028
OWNER NAME: APPLICATION SUB DATE
CHESS DRIVE UITE K04/09/2001
• PHONE: SANITARY NO. COIVIROLNO.
cZ ARCHITECIENGINIa : BUILDING PERSIII'INFO
w❑� iRBLDG ELECT "LUMB MECH
z y LICIiNSaU CON'IBACI OIt'S DECLARATION .lob Description '
O 0 I hereby ad"or Mm I am licenwd under provisions of Chapter 9lmmractwi tg
Fos-j with Sill fbommal of Uivisinn3nfihe Business and Yndessanns Cale,vnJ my license
=y [)am ,recatrdelfcea REPLACE WATER HEATER.
m a License Class 1 ie.P
a 3 L N Uwe Contactor `
ARCIIITECT'S DECLARAfIUN
r_a
on 1 undeomnd troy plan shall be osd nx pct bl is metrao
r—
wo o Licensed rrnra.nietnd
,e OWNER-BUILDERa,1;n DIiCLARATION /
u1 I hereby risco that I;un nctnnt tram the Cessions r Licence law for the
%Inswing mown. sept it]IULS. t.aImi,a aminase.demob h,or mop y city or county D
6 rio mquimsne.also recomwet,aloe itrWmsuh permits ore a signed
any structure
a3$ prinnnita issuance.also myuims the applicant for such fcrmiuonleasigned.vammem
that he islicensedwauam tonic previsions of the Contractors License Law(chapter 9 Sq. Ft. Floor Area Valuation
(eontn,onc ng whir Sectio;700(r of Division 3 of the Business and Profession,Code)
or Boat he is exempt Immir, i and the h sic Iia the alleged eseatmi...t,Any violation IR C:;RL71
-
or Nc,fl 19031.5 by ary aPplica..t Ibr,......I,ubjcatx the apnlwan,to a dviI pendty
el..ot..tore than n,e lnamfma dollar,(S500). APN Number Occupancy Type
Cl,us owner of the properry.or my employees with wages as their sob compensation. e n
will do the work.and the structure is not intended or offered for sale(See nus. ` - Re aired Inspections
Business mid Pmfes ions Cara
de:The Contctorlise
, cenLaw does not apply to an q ns P
owner of pnipemy Who builds or improves themon.and who dms such wtak himself
or through his ownernoloyees.pmvidedflut such ininmvemenu are not intended or 502 — FINAL PLUMPING ENERGY
altered for sale.If.howeverthe building or iniprovammnt is sold within once year of
`mnnplednn,the own—holder will have doe hods..(ofproving that hedmmtt build or 906 — GAS TEST
pmr a far pan cul,de.,
t , ae
C 1,a,owner of he pmpeny.air exclusively commcthig with licensed conlraclme re 507 — FINAL PLUM$ING
cansauct the project(see ]toil.Business and Professions Cale)'rhe Convector's
License taw does nor apply a,an owmr n(property who Wilds or papooses rhemon,
and he common for such projects with a emnnaamds)licensed Pursuant no Ne
Commemr's License Law.
❑1 ant exempt under Sec. ,B&P C far this rteu,n
Owner [).,Is
WORKER'S COMPENSATION UECLARATION
I herehy allinu under twedly of perjury oro of the following declinations:
• ❑ I have and will aminmin to Certilical al Concent m seIf-iram, for Worker's
Compcnsaion, m provided fur by Section 370D of be LaMar Code, tin rhe
petfarmaree of the weak in which this pcm n is issued.
01 have and will maintain Worker's Coopnnmrion Insurance,an requited by Section
37111 nr the Labor Code,lar the lieof...aa ce of the work for which this permit its
issued.My W..orr's C....yanaalow hisura,c cannier and Polley norther ore:
Carrico nnlicy No, ,
CERT IFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lois action mid not W completed if the pennir is for one hundred du m,
1510111 or Ica.)
I ecnity that in the locrhannance of dm work tot which this permit in Issued,I
dell trot cmpiny any peace'to ony Ina..ser so ax n,become n,tbjcct et,be Workers
Cotttncession Lno—of Calil.....a.D:nc
AnpIa,ma
N,FICE'ID APPLICAN'p It.after making this Cenhicam of Exemption,you should
become subject a the W'orker's Compel inn provisions of the Labor Code,you ansa
Q 0 forthwith comply with such provisions ar this Iicnnit shall he JeemeJ mouser. _
Z
FN ee the.is coN1a?LADING AGENCY
a > I bembye nnit that them iss cnnstmnion Iendi ng agency for the perbarmunce
W of rhe Burk far wbiah thix pe....ot n numJ(Sec.lIH)].Civ.CJ
L Q Leader's Nance
Z landcr,Address
JdrJrcys
V 0 1 certify that I hm'c mud this application and pate that the above inlinination is
Rx [.. ammo.1.,me to comply so ith all city and county ordinance.and sate laws miming
t..) ar Wilding construction.and hereby authriae mpmseniatiees of this city to enter upon
the almvnmemiomd propeny Imo inspection purposes.
Fox L
We)agree m.save.indenmify and keep homeless the City of Cupertino against
Z liahilitie,judgmenrs,aaa..and cspcnsen which may in:toy way;acme against said
V -FT. city .amwyuence or the granting of this permit,
APPLICANT UNDER$'I''ANIIS AND WILL COMPLY WITH ALL NON-11i Issued by: Date
SOURCE REGULATIONS. y'
Tgtmmm orannncatiucetifmcl"r nae Re-roofs
HAZARDOUS MATERIAI 1 DISCLOSURE
Will do,applicant or future Wading acc nsiont sum or handle homNrms neutral Type of Roof
as defined by the Cupertino Municipal Gale.Chapter 9.12,and the health and Salcry
Cade,Sectio 255321:p)
°Yes C)No All roofs shall be inspected prior to any roofing material being installed.
Will the appuetnr or metre buddiig e...... it„e equipatent ordevieaa wIii,li If a roof is installed without first obtaining an inspection, I agree to remove
..tit ea'anlous air eonaun i..attts os defined by the Bay Are,Air Quality Manugc..mrt
uiwrien all new materials for inspection. Applicant understands and will comply with
C Yes ❑No all non-point source regulations.
I nave read the Imrarrous materials myuimments ander Chimer 6,95 of the
Califomix Health&Safety Code.Sections 25505,25533 and 25534.I undersand Iha
if the building docs nm currently have a teaanL that it is my mspatmibility m notify the
occupant of the requirements which must Be met prior ur issuance of a Certificate of
OCCupan"` Signature of Applicant Date
Own,—,auderiAdngen, Date All roof coverings to be Class "I3"or better
OFFICE