03010034 (2) CITY OF CUPEWrINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ¢
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.
21096 WHITE FIR CT 03010034
OWNER'S NAME: 970 E . MAIN ST, SUITE 200 APPLICATION SUB DATE
DAVID CHIN 01/07/2003
IONI7: (415) 566-2209 SANITARY NO, CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION Job Descri seen �'�
®A ■
<iw F I herehy affirm that 1 am licensed under provisions of Chapter 9(commencing p
<� with Section 7gXd of Division 3 of the Busineat and Professions Code,and my herrem is ^ E
Z O< infull 'Classee I. (o REPLACE WATER HEATER.
Ia4 Lice im Class_ Lie.N�
o=no Date ContrmrorJAN 2 7 2003
=—� ARCHITECTS DECLARATIO
o.Q w I understand my plans shall M used as public records
�4QU Ip��
Licensed Professional BUILDING
C— OWNER-BUILDERDE DECLARATION
R a, I Lathy affirm that 1 1. exemptfrom the Cnmvncmr's License: ny r Law cu the
—pO following reason.(Section 703str Business and improve,
deroli Gale:Any tiny nr county
sae which myuircs a permit m construct.alter,improve,demnl'rsh,nr repair any structure
prior m ss
its ivance,also requires the applicant for such permit m rile a signed statement .n
?< than he is licensed pursuant m Ne provisions of Ne Cununcmr's License Law(Chapter 9 Sq. Ft. Floor Area $V62titlon
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y Nal he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for is permit subjects the applicant to acivil penalty of Occupancy T
not mom Con Eve hundred dollars($500). P Y YPe
❑I,an owner of the property,or my employees with wages az their solo compenauon,
will do the work,and the svucsum is not intended or offered for sale(See If44,Businen —
nnd Pmfessimns Code:The Convectors License law does not apply m an owner of 506 - GAS TE vire nspec Ions
proper who builds or improv¢thereon.and whodoes such work himself or through his
own employees,provided that such improvements am not intended oroffered me Mile.If. 507 — FINAL PLUMBING
however,the building or improvement is mid within one year of completion.Ne owner
builder will haves the burden of proving than he did not build or improve for purpose of
sale.).
❑1,as more of Ne progeny,am exclusively contracting with licensed contractors to
construct the project(sec.7044,Business and Professions Code:)The ConvacmrE Li.
ccom Law does not apply in an owner of propcny who Wilds or improves Memon.and
Who contracts for such projects with a comtncmr(s)licensed pursuant o Ne Comrwmr's
License Law.
❑ I am exempt under Sec. B&P C for this¢room
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Convert self-insum for Worker's Compen-
toon,us provided for by section 3701 of the Labor Code.far the performance of the
work far which this p.it is issued.
have and will maintain Worker's Compensation Insurance,as tequircel by Section
700 of the Labor Code,for Ne performance of the work for which this permit is issued.
My Werke' aatip¢Ipsumnpr carver and Policy nyt�eLam
Carla: 7L"' z PolicY N^.:/{ac 5123-0Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mis section need not M Completed KIM permit is fornne hundred dollars H 100)
or met)
1 certify that in the Performance mf the work for which this permit is issued.I shall not
employ any person in any mannerso az m Mcomc subject h,the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:11;after making this Cenilicate of Exemption,you should
hecome subject to the Worker's Compenmlion provisions of the labor Code,you must
OO fnnhwith comply with such provisions(it this permit sholl M deemed revoked.
M CONSTRUCTION LENDING AGENCY
E-s l hereby affirm than there is a Construction lending agency for the Performance of
the work for which this permit is issued(Sec.31017.Civ.C.)
1 Q Lender's Name
r7 Z Lender's Add..
U O 1 ccnify Nat I have read this application and Mute than the show information is
l4 F toren.l agree to comply with all city and county ordinances and shoe laws relating to
0 building construction,and hereby,authorie,mpmae^utives of this city or enter upon the
U.l shove-mentioned property for inspection purposes.
F 0., (we)agree to save,indemnify and keep harmless the City of Cupertion against
Vy liabilities,judgments,costs and expenses which may in any way accrue against said City
7 inconsequence of the granting of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SOURCE REGULATIONS. /per
Z/"� Re-roofs
Signemrc of APPlicat DAM,
te
HAZARDOUS MAtERIALS DISCLOSURE Type of Roof
Will Nc applicant or future building Occupant Move or handle ha ardous material
az Defined by Ne Cupertino Municipal Cork,Chapter 9.12,and the Health and Safety
code.Scmlon25532t07 All roofs shall be inspected prior to an roofing material beim Installed.
❑Vcs mom- P P � Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
min baeallous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Iducs
isuin7
I haveaced NehareNnusmnmrials5533 4255 underdea= Lheifthe building its Ilc^W&Safetyhaw a tenant,that it i 2my r and255:44.1 to miftmd a tacthe building
nm curcn0y hove a tenant,Nnt B is my resrymslblllry m nntlfy the rccup I of Nc
cyuiremenhe mm pd oissumrenfaCcnilicamofQcu eySignature of Applicant Dale
wner ora«th^risda rt /1,
a,c All roof coverings to be Class "B"or better