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01020108 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRIcIS: PHRMT NO. 10600 WHITE FIR GT WATER HEATERS ONly 010190110A OWNEWS SAME. APPLICATION SOB DATE PHONE: SANITARY NO, CONTROL NO. J w rc zARCHH ECr/F.NGINEER: BUILDING PERMIT INTO h III.IIC BI.ECr PLUMB MECH F.0 u I=ed a = n n, r, lnl'RArandcrsDimorsoAnoN JobDescri tion uccr+san a o S-0 l nerebv d' icensed ander renvislnn,of Chapee n mmny license P P,arta with full foreladd afeca. on3nf the Boniness and l'mfenrinns Cnde,and mylicense g y i J m full fore,and[Reel. 5 6 License Clxxx Lie.M %eW Date Contractor REPLACE 40 GALLON GAS WATER HEATER li 3 a oFn ARCHH-rCI"S DECLARATION $_L$"u�4 I undenlund my plans,M1ull be useA us puhlic re'nrJs G7pa. O Liccnwd P,acnlonal OWNER-BUILDER DECLARAl'ION o I hemhy.uffvm thm 1 pmI caeedpt from the Contractor's Licence Low for the F Z a following reason.(Section 7lD LS.Ruxincxn nnA I'Iasl'c dare Code Any city titer ly ae�o which requires a p.it m amswa,ober,art, .Jenudish or repair any xrnamure a_ pdono it,ixxmm,e.aho legaber menapprlCUlanarsrlcn pennh to filen si,ardammmctn that he is ficenxed pursuant to the provisions of the Courtrai License Lwtcnader 9 Sq. Ft. Floor Area Valuation (commencing with Section 70X11 of Division J of the Business and profession Corel or(hat he is e`cmpt Ih,d1 i and the basin fpr Ise nllegad eaa.....f n.Any violadnn of Section 7871.5 by any applicant fire a permit,til the opplic'nua a civil penally of not loom man five handsel dollars S%d. APN Number Occupancy ypc ❑1,d�wnerork.and It,ly,od Inti osoecxwanwagera,mersale epmccm7(UL will do the work,mW lie ode T e Ix not Contractor % or attend lin anon apply it)an owner of and Professions cafe:Tire comma:s,ndLicense o d does not apply w an egwred Inspections r ugh In%ow Who hnder on'Imp ed t mereoh,and who[tax xrlen wank mm�seE owner las awn eovever,the provided that salt hepmvemeol are not im year or 'fiendfor sale. vvhaweren,me bmdmgerimpn'vememnsole he did ane year of 502 — FINAL PLUMBING ENERGY ipmpmbon,pu owner.nnuder foul nave me nrinlcn orproving oral hedid ma nmin or 506 — GAS TEST mprove for Imgane ar sdel. ❑Las owner of tire'ropcny.alncaea,ivdycamrald.,evmlicensed ammewrxlo 507 — FINAL PLUMBING conduct the project(Sec.7044.Il ad Profe,eiom Crda:)]be Contractors Licar,c Law Joe,nal apply m nn npw'ner fir pngaaly wit,band,fir in,a.vI,Ihamon, and who contracts for such projects with a conwendO licenser)pursuant to the F! Connneods Liconsc Low, �� ❑I Linn c.eapt audit,Sec. .R&I'C lin This reason °w"°` Dat` JAN 1) 4 2002 WORKER'SCO DavaAI'ION UHCLARAI'ION f i hereby rallied under penally of perjury one of lie following declurmio-: I terve and will In'oinmin In Ceniflcat,of Conserv to self-iroua far Wn IIP, BUILDINGCompensation. as poevided Iia by Section 3704 of the Labor Calc, for the pvrlil..nnnec of the work for whish,lik permit is[,,.ad. ❑1 have and will maintain Worker's Cuntpensation Insurance,ar dep ived by Section 3701)of me Labor Code ser ala pem....o nee of me work for wmen this prannit is sued.My Worker s Co npensalioa In,amaac rudder and Policy number are: Carrier: Policy Noy'. CERTIFICATION Olt EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thi,xcclion need nm nit enntplcard if the remail is lin ane hundred JolLnre (SI W)or legal I ar(ily that In Phu pofnr in....c of the work for which This penia is isxned.1 ,hall not employ ony person in any resound m an In become subject to me Workes Colopt,nxation La's If Crdifo,nia.Date Applicant NOTICE TO APPLICANT.If,oftar making This Ci nillcam of Exemption,you should beerna'abjccl ache W..kedr Cat arsaliunprovisionsof tine Lahr,Code. earnest '0 Q Ibnhwim comply x'ith such pnu'Isi no or hits perinit shall be t eir revoked. F ` CONS'I'RUCI ION LENDING AGENCY ai > I hereby dived that hem is a construction lending agency for the performance of Ph,work fn which Ihlx pn'ntit is issuul(See 31197,Co,.C) Q Idnder'x Nrmc 0 z Lender's Address U I cenify that I have read this application and slate that the above information is ' !L Fyn a ace.1 agree la kvmply with all Illy and oudy ordinunca rod.,ate Iowa relating O mhnilding rem,trvction.and hereby aulborire mpm,enwliveu of this city to enter upon } W the ahwe-mentared pmpcny for impection purposes, E•, y (sued agree to lave mdenndy sad keep haemes,m�City or Cupedula ag;Iio,t Vi liabilities,judgmenn,costs and espcme,which may in any way ace is against raid U 7 Chy in c�n...... enl'(he grrongol'this pcnuil. - APPLICANTUNDERSTANDS AND WILL COMPLYWII'llALL NON-POINT Issued by: Date SOURCE REGULATIONS. y' Signature of Applicanvcamramr Date Re-roofs HAZARDOUS MMERIALS DISCLOSURE? Will the appliC:rot or boom mtihung occupant store or handle vu,nonx molerial Type of Roof a.defend by the Capenine Municipal Code,Chopbx 9.12,and the Health and Safety Code,Scelion 255321'11 ores 0 N All roofs shall be inspected prior to any roofing material being installed. Will the applicant ortopic building occapamascequipmemo,devmeswhich If a roof is installed without first obtaining an inspection, I agree to remove Fmil IIaea'(Nuu,air contaminates as defined by the Bay Amu Air Quality Management i,lrmlall new materials for inspection. Applicant understands and will comply with ❑Yes 0 N all non-point source regulations. I hove scar)the ham,do.,mmcrii,fequiremm�ts afire,Chupmr b)5 of Iia California Health k Safey Crde.Sections 255115,255]3 and 25534.I utdmund that it the building does'nal camenlly Itave n leach,fin II I,my RTptm,Ihldy l'nallly the occupant of the mquireinenn which must be user prior e,issuance of a Ccniticate of Oecnpnncy, Signature of Applicant Date Uwnc,or'tlmnr,ed ageal Dme All roof coverings to be Class 'B" or better OFFICE