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
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= 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