00110037 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .;, CONTRACTOR INFORMATION: '
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BUILDINGA&1111 0 LA JOLLA CT JUST WATER HEATERS I ''JB"II_T"D'001.10037-
OWNER'S NAIMM SHEAU—SUEY .AND KAREN- IAI—HW '1764 NATIONAL' AVE APPLICATIO11 SU�DATE/2`�
; 0m '
HOSE: (.510) 2'93.-9901 . SANITARY NO. IL�G CONTROL NO.
O C ARCHITECDENGINEF.R: rJ BUILDING PERMIT INFO
u_ BLDG ELECT PLUMB, MECH.
S?rI ICFNSI DCONTR\CTOR S DECLARATION - _ Job Descrl tion
or e II by I'1 'vh tl "e I eo 1. .' n.- fCM1 pl r)[c nnetun6 p
I-
an Section eammo :emn3nitneBa and proRxaia.Lmd aq,ylicense REPLACE 40 GALLON GAS WATER HEATER
m z is in full tome and cRcu.
o d hiaox Class Lic.N
�W5 One - Counter...
"t a V ARCHITECT'S DECLARATION
e 1 understand my plans shall be used as public records s -
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a C O LicetiwA Prolesxional
OWNERBUILDERDECLARATION I
1 hereby.111.ohm 1 am exempt from he Contrncmr's License taw lin Ne
O following reason.($rinif t ]11115,Busincez and improve,
d tions h.or Any city ..twenty -
a,z et which it, tree a Ica'mit m construct,aha, ,for armnnit I fi repair any structure
3: primlo t I: rcqu thovisio< II r: chn fie g N.I mein
marl licensed agpursuant t top nn Contractors L h Chapter)Cubic)
- Sq. Ft. Floor Area Va u�t( �t ry
(con rtht dremnconalone v"T c s(lea Buku a1 almsons Grde .
or that he ix tempt tnrrefrnr and the hasie our me alleged the exemption:Any violence' -
of station]0}1.5 by any applicant burn permit subjects Inc avPlicam to a civil penalty
ofnnlnmon:manfive hand redmonal.a5oo). - '. A1-�-,�Luj16tk?. 00 Occupancy Type
°I.."a mrnfinevro,any.nm,anpli'dr,wilewage.eastheirsuiccumgenmden. f,{ r
ward In - k- le, r r I t da Breafor:a (ppt.nw, r FIN q�-JL.CJiR fSi �NERGY
Bus aPnf.. :Cxl ThContractor's, - I elms. rappiyman 502 — e i ❑t-
w through
mien) cl l II: almprnc ah hirrprandwhoa M1 intended
_
oferedgM1haownhamesyres. buildinmal.nthvementis%oldarenotareyearnr 506' — GAS TEST
offered for sale.If,however,rbc building or improvement ornt n sold within nuc year of
icompletion, nenwner-bmmrrwalnaxemrnamennrprnvmgt11.anneal"°`"ill°' 507' — FINAL PLUMBING
mprnvt rn pttrp..aa arxnle.). � �, - '
❑L.0 omnrr of the propeey,am exclusively contracting with licensed contractors to
ons ruct the project(See.70,LL Busincez and Prnfexsi..ns Code,)'I he Contractor's _
Been,•Law docs not apply to an ownerof properly who builds to improves thereon,
.rid who reroute,it,,such projems with a cmammnd,) licensed personal us the `
Cnno- tohecLicense law,
°1 am Cacmgl under Sec. .B&P C for this mason
Owner Date
W'ORKER'S COMPENSATION DECLARATION
I hereby aB"urn miler psaralty..I'perjury on1 of the Ibllever,declanni...e,
I I have and will maintain a Certificate of Consent nm alf-inmre for Worker's
m pe :Y as pn mod f. by Sec 3700 of the Labor Code, for be _
,rilmocracrof Id,sun k bar fish Ihi,permi,i, ,taed,
°1 have and will amount.Workers Compensation Insumnee,a requital by Section
_ 3700 of rho Lahur Code,far theµh nnuire of the work for which his permit iz
sued.My Worker',Compensation lnsnnmcl cruder and Policy number are _
Cartier: Polio No.: ,
• CERTIFICAI'IDN Ols EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This section need not b,completed it the Wman is for one hundred dollars '
(blab a hes.)
1 certify mal in the perfarrmrnce of the work for which oris pe.t is issued.1
shall not employ any personam,n r to as to become subject m the Wnrkv, '
Compenvarit l.1—ofCYlikorta."Dale n -
Applicant
NOTLCHTOAPPLICAN'I:IL afnemmiking this Cenifitarnf Exemption.You should s "
Z Is—ow,subject on the Worker's Corpensminn pro Binns nl the Lalwr Cude,you not,
Q fonhwirh"only ly vvuh enol profauns err this permit 0:01 he deemed revoked. - -
Z
4 CONSTRUCTION LENDING AGENCY
ai > I hereby affirm Thal them is a cmo natin.lending agency fur rhe peromerm e
of the work for which this penult Is iaued(Sea 3097,Civ,C.) n
L Q Lender's Name
D Z Lender's Address - ..
V 0 1 cenify the I have orad Ilik application and state mu the ubma iant(rn.wlna is _
IY F. coned.I we m comply with all city and ,,any trobalnces and sure laws return, _
(,
to building cons0uction,and hereby auhoiu mpremnu0ves of this city to enter upon '
r Ii7
finalists,mentioned progeny for inspection purposes.,
[r 6m -,IWe)agrcem sive,inacmnil'y and keep bn...leis 1111 City ulCupwrionepatit
Zn liabilities,judgments,towns and expenses which may in any way accrue against said
U Z City in cmnsequende of the granting of this pennin. .
APPLICANT UNDERSTANDS AND WILL COMPLY Won ALL NON-POINT IggUedb - Date -
SOURCE REGULATIONS. y:
Signature of ApplicaroWwatractor Dae •Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE '
Will the ttpprtcamt ,mire 11tdldrng swatgum oemto handle Ima.a.ole nan-1 'type of Roof,
as defined by the Cupertino Municipal Cade,Chaper 9.12,and the Health and Safety -' -
Code.Section 255320?
°Y"" °N" All roofs shall be inspected prior to any roofing material being installed.
Will the ppliant or from handling pat me eqmportunt or devret,s which If a root is installed'without first obtaining an inspection, 1 agree to remove
` it h dcontaminantsJ f ed by theBay AA Quality ty M gc ent
emit t all new materials for inspection.•Applicant understands and will comply with
°v °N all non point.source regulations., .
1 have reed the h ardous material:requirements under Chapter 6.95 of the
California Henllh&Safety Code,Sections 25505,25533 and 25533.1 understand that
if he hunting dove not currently have it ecomr.that it is my respo.c,du ity to nut lfy me -
cupant of[be requia arce;which must he uta poor to issuance of a Certilicae of
Occupancy. Signature of Applicant ,Date
Owner or aammdaea.,car - Dale All roof coverings to be Class `B" or better '
OFFICE