04110031 CITY OF CUPER'I•INO �'�NAw
BUILDING DIVISION PERMIT - CONTRACTORdINFORMATION�6 ..
6UILDING ADDRESS: PERMIT N0.
WATER HEATERS ONLY 04110031
RPRT- AVE;
W NER'S NAME: PERMIT L4UE DATE
12
E:'
r SANITARY OL NO.
9:70 E. MAIN ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT • PLUMB MECH
y00 LICENSED CONTRACTOR'S DECLARATION O O
in� 1 hereby affirm that 1 am Hamed under provisions of chapter 9(commencing _ lob Deserip[i Q
Ovid,Section 7")of Division 3 offc Business;and PraferpaoCcde.andmylicenseis qLED,
%+ y in full lone arta effcc. d-5 '7�
Sq? 0ful Lic.N 77 REPLACE WATER HEATER .
Z¢¢:, Date Comupor - - - -
,vWu - lundcrstanJ my sal ans AR
CH Mused asECLARrcenrT�Js V -
2Z 2004
u.t; Licensed Professional o�oL�PLivap
OWNER-BUILDER from
DECLARATIDN 001 hcrehy.(Tw Nat 1 1. ucmpt from Ns.Cnntrumh a:Any c law far the
p O following reason.(Section]Ip L5,Business and Pmfeazium Cork:Any city at county
1$� which squirts a permit to construct,anus,improve.demolish,m repair any atrumure
Fteiprior toils issuance.aku requires theapplicam for such permit,.filo a signed susement
Mat he is ueenaed pursuant in the prevision of me Cominc,.rs LJance Law(Chapter 9 Sq.Ft.Floor Area Valuatio
i- (commencing with section 7")of Division 3 of me Business and Professions Code)or -
6" _ ren he is exempt therefrom and the basis for me alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects Me applicant o a civil penalty of 3.�-Dq i.N.
oat ream than five hundred dollars(5500). /91`V V 'Ldjer0 0 Occupancy Type
Q I,m owner of the pmpeny,m my employcm wire wages as Oteir sole compensation.
willdo thcwort and theswemreunot intended oroRcrtd forulc(Sec.]Odd,Bassin,. -
add Pmfesians Code:The convenors name Law does Inst apply m an owner of Required Inspections _ -
pmpeny who builds or impmvus demand,and who doessuch work himself artitrough his '
own employees.Provided mat such improvements are not intended oroRered forsale If,
however,the building or improvement is sold within one year of impletion,me mimst-
builder will have the burden of proving mat he did not build or improve for purpose of
plc.).
❑1,as Owner of dm property,am exclusively contracting with licensed amracars to
construct the project(Sec.]Odd,Business and Professions Code:)The Commictor's Li.
ams Law docs not apply m en owns,of property who builds or improve Monaco,and
who concocts for such projects with a co mdctof(s)licensed pursuant o the Condenses
License Law.
❑Iamexcidprmnim Sea ,Bk PCforthisrexsim
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby atiw under penalty of fiction,one of the following dalantions:
ave and will maintain a Certificate of Consent to self-insure for Worker's Comped-
0
.u provided for by Section 3700 of rAe Labor Cade.for dm pe,fowence of the _
ork for which this permit is issued.
ban and will maintain Worker's Compensation Insurance,as required by Section
]OUof the labor Code.for Me pcRarmenceof Me work for which this permit is issued.
My Workers Com nsa. lnppsurana arrim and Policy number as:
Cameo t•a^ �• Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
(Oris section need not be amphOad if tite permit is foronc hundred dollus(SIM)
or less.)
1 ccmlfy that in the PerflswancC of the work for which this permit is issued.I shall not
employ any person in any manner ad as in become subject o de Worked Compensation _
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject,.Me Worker's Compensation previsions of the Labra Code,you must -
.J z forthwith comply with such prnvisinns ar this Permit Mail be decided rooked.
Z O CONSTRUCTION LENDING AGENCY
IhenabyaRrm this mere iso eomtructinn lendingagcney to,the perfsmanau(
ai.•� me work for which his pewit is issued(Sr..3097,Civ.C.)
QLender's Name
=z Lenders Add= _
U O 1 comfy that I hum(Cad rets application Md state mal deo above information Is '
L, f•' an.,1 agree to comply with all city and county on inances and sure lea relating th
C V building construction.and hereby androids representative Of this city to enter upon he
r a s
hove-mentioned property(or inspection purposes.
(Ws.)agree to save,indemnify and keep ha,idless me City of Cuponino against
UFy liabilities,judgments.ensu add.1.which may in any way accrue ag.I.%said City ///non
in eoniquenec of Me granting Of this pewit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE
4Re-roofs
Signmurc mf Applicanonwmor Dale
I
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will f applicant or funds building Occupant store or handle hena,daus material
az defined by he Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
cW Secondy.2ss32a)' All roofs shall be inspected prior to an roofing material beim
❑Yes i1a� P p y g g installed.
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hat anus air contaminants is defined by me Bay Area Air Ouality Management all new materials for inspection.
rictT 11
(]Ycs L`1aau�
1 have mad me havamous materials requirements under Chapter 6.95 of me Cables,
nia Health h Saf lyCode,Sections 255)5.25533 and 25534.1 unrbrstanJ OW if ft Wilding
Jars not curtcml,have a temam,mat it u my des omihility m and ly dte aaupsm of me
nod Is. tbcmetpnorw uamaofaCcmfipmorOc ic,. Signature of Applicant Date
•/ o
Owner ser authorisJ aF alt Data All roof coverings to be Class"B"or better