03010101 (2)0
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CITY OF CUPER'1'INO
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BUILDING DIVISION PERMIT'CONTRACT,INFQRMATIO
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BUILDING ADDRESS
WATER HEATERS ONLY
PERMI"FNO.
20338 VIA PALAMOS
OWNER'S NAME:
O03010101
970 E. MAIN ST, SUITE 200
APPLICATION SUB DATE
MIKE CALLAN
01/17/2003
ZONE:
(415)566-2209
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINFER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSEDCONTRd TFOR DECLARA'T'ION
I hereby I Chapter 9
Job Description
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affirm that under
under provisions of (commencing
um f me Business,
with Section 7000) of Division 3nl thm Buxinc%s and Prnfex inns CoJc. and My license is
in mufott Iafte
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REPLACE WATER HEATE R
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Liu ,a`�3L Lic.M�
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Dalc_ Cnntractm
ARCI11liCT'S ARAGON
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MAR 0 5 2003
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1 undcrnanJ my plans xholl he used ax
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OWNER -BUILDER DECLARATION
BUILDING
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I hereby affirm that 1 am exempt from the Cimmod m's License law Air the
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fallowing reason, (Section 7011.5. Business and Pnlfcaions Ctale: Any city or county
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which tequircs a Permit In consumer, alter, improve, demolish, nr repair any structure
that rto, islcefnsed arttothe so ler Contram1111n cense Lin e,IChrp lr9
Sq. Ft. Floor Area
$Vy�ption
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pu provisions
it Section70c)(1)and rth to Professions Cale)
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usnorxueenoclaonsCodmru
(commincingwiapaaaamtotncpm.ivinoaoftheBusinessor
of hadisof
that he is attempt
that he is exempt nc�rcfmm and Nc basis for the alleged exemption. Any violation of
aged exempt
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Occupancy Type
Section 7031.5 by any applicam for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (23001
❑ I, as owner of the property, or my employees with wages a their sole compensation,
will do the work, and them --mum is nut intended or offered for rate (Sm. Business
502—FINA Rty
and Profusions Code: The Contractor's License law does not apply in an owner of
506 - GAS TE rlgmre nspec Ions
property who builds m improved Ihemon, and who does such work himself or trough his
tun employees, provided that such improvements are not intended nrolfered for aide If,
507 — FINAL PLUMBING
however, to building or improvement is Bold within one year of completion, to owner
builder will have Ne humen of proving that he did not build or improve for purpose of
salad.
1, as owner of the properly, am exclusively contracting with licensed contractors in
member Ne In (Sec. 7M . Business and Professions Cook:) The Conmctols Li.
cense law does not apply m an owner of property who tables or improves thereon, end
who contraeu for such projects with a commesor(s) licensed pursuant to Ne Contractor's
License Law,
CD I and exemptunder Sec. ,B&PC fm tis mamm
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of Perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Cent lien -
.he . m provided for by Section 37M of the tabor Cndc, Int Ne peRomtantt of the
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
11)of to Labor Ceske, for the perfnmmnx ofthe work for which this Permit is issued.
My Woker'crensitansislin se:uurier and Policy nu berare: 0
Carrico WlriLa, �--"�� PnIicY �%B'S_--3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
olissecrion need nor W comple al if the Permit is boom hundred dollars ($TIMI)
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I ccnify that in the Performance of the work for which this permit is issued, 1 shall not
employ, any proom in any mann r so as or become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICETO APPLICANT: It, after making this Cenifieam of Exemption, you should
hccome subject Io the Worker', Compensation provisions MOW Labor Cute, you hoom
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forthwith comply with such provisions or this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby shim Nat there is a construction lending agency loo the perloramom of
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rbc work for which this permit is issued lSec. J(N7, Civ. CJ
QLender's
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Lender's Address
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1 ccnify that I have read this application and state that the above information is
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correct. l agree to comply with all city and county ordinances and state laws mlaring 10
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building construction, and hereby autorim reprcuntativei of this city to enter upon the
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show "mentioned property for uoreetinn parlous.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against read City
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in consequence of the granting of this Permit.
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APPLICANT UNDERSTANIJ$$--AAO0IIpp WILL CO LY WHIZ ALL ON INT
Issued by: Date
SOURCE R EGULATIONS. J g ,f / 3
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Re -roofs
Signature of Applicant/Cunlraaor Dare
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the aan
pplict ser future building occupant xrore or handle by rdoua material
as defined by to Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, section 253J2M)7
All roofs shall be inspected to an roofing material beim Installed.
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prior
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If a roof is installed without first obtaining an inspection, I agree to remove
Will rhe applicant urJ'umre building occupanl use equipment or devices which
haaallous air' etmraminants as defined by the Bay Arca At, Quality Management
all new materials for inspection.
Dislrie
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IIIave read the hamNnus materials myuiremcnts under Chapter6.93 nrthe Caldinr
ria Hcalt&Safayhawa
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tenant,of tog
Jlcs mol currently haze a tenant, tat his my rcsglnsihilily m notify tM IccuPan of to
myce ens dill tomoury uoccu an
requirements whicM1m Pdonniss cc nfu Ccnifcumnf0.�c p: cy.
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Signature ofApplic<yr Date
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All roof coverings to be Class "B" or better
Owner or truth mad n, „e