03010171 CITY OF CUPERTINO
BUILDING DIVISION PERMITCON_y RACTOR INPORMATI6".
BUILDING ADDRESS: HOT WATER INC PERMITNO.
6435 BOLLINGER RD
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
WONG BRIAN K 01/28/2003
IONS: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHI ECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
�u I hemby affirm Ibut 1 am licensed under previsionsof Chapter 9(commencing p
Th Scetinn 7lXXB of Division 3 lticJYusincss end Profcas aCowlc•andmyliccnscis
n�fpp fnrce.w ertml �� �Z REPLACE WATER HEATER,
ZOgj� L Lic.N
Oo W Date
tA Clf-0rrS DECLARATIONA
C I on crsund my plans shall he used as public records
KOU
m ik C Licensed Professional
WOWNER-BUILDER DECLARATION
u� X I hcrthy affirm
that I am exempt from the Conuamnr's License Law for Ibe
W0 14
22 following ma on.(Section 7031.5,Business and Pmfessi us Code:Any city or county
which requires a permit to construct,after,improve,demolish,or repair any structure
prior m its issuance,also requires Limapplicant for such permit to file a signed statement
�m�m<
I WtWisftce.cdpursua.I an lW provisions of the Cim isim's Liecmc law(Cmuc,9 Sq. Ft. Floor Area $Y"tion
FS (commencing with Section 7003)of Division l of the Business and Professions Code)or
Net he is exempt
'00
and the basis for the alleged exemption.Any violation of
Section 7031.5 by my applicant for a permit subjecu the applicant to a civil penalty of a Occupancy Type
not mom than five hundred dollars($500).
0 Lasowner of the property,.,my employe.with wagesm theirsolecompensation,
will do the work,and the stmetun Brunt intended or offered for sale(Sm.7W .Business —
and Professions Code:The Contractors License Law dams not apply to an owner of506 - GAS TE vera nspec Ions
progeny who builds or improves thereon,and who does such work himself or through his
own employe.,provided thatsuch improvcmcna are not intended muttered for sale.If. 507 — FINAL PLUMBING
however•the building or improvement is sold within oro year of completion,the owner
Wilder will have the Wrden of pmving Nat he did not Wild in improve for purpoa of
sal.).
0 1,as owner of the property,am exclusively contracting with licensed comractors m
co espat the project(Sec.7004,Business and Professions Code:)The Conuecmts Li- P
RED,Li-
who
Law docs not apply c m with
a of property who Wilda rs improves Corton,ors.
who contracts Lawdo forsuchply W winacuntraper(a)licensed pursuant to the Contractors
License Law.
0 lameacreptundcrSce. ,Bk PCforthisrucen
Owner Date
WORKER'S COMPENSATION DECLARATION
1 Wreby affirm under penalty of perjury one of the fallowing declammus:
I ben and will maintain a CemiOcate of Consent it self-i.um for Worker's Crimper.
ration,as provided for by Sectionbo
3700 of the lar Cade.for Be'do..of Oc
wart for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,a required by Section
JRIOof meV or C,Xle,far the pc do ante ofilm vmrkforwhwh Owpenniu(ssucOf
My Worker's rimlCnsaf rclnW furan erticr and Palk/nu r �s-E
rticr. ` Inl/•L vl PolicY,'Din/
C sRTI•KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not rte completed If the permit is formic hundred dollars($1(X0
or less.)
I certify that in IW perfnmunce of the work for which this permit is issued.I shall not
employ any person in any manner sn as In become subject to the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Ceniricam of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
OO foMsh
with comply with such provisions or this permit all M deemed invoked.
CONSTRUCTION LENDING AGENCY
[-w 4 I hereby affirm Out them is a convection lending agency for the pedinmanee of
Ci r7 Nen work for which this permit is issued(So..ID 7.Civ,C.)
WJQ Lenders Name
Z Lender's Address
U O 1 cenify Net 1 have reed this application and sum Nat the move lot ..tion is
Dr P Ounces.I agree to comply with all city and county ordinances and sum lawn mtating to
0 abovingconsuuctian,md for
ins authodm rtprescnutiws of mice city it)enter upon Be
W shove-(We)ued agree
lin minifyinn keep ens.
(Wen)agmen to save,indemnify and hcep may
in m me City of Cupenst against
V y inconsequ consequence
of tu,c.uand experts.which may in any way same Against mid City
Aconscy NT of the Ugrunfirig NDERSTANDS
thispermit.
AP ANT UNDERSTANDS AND WILL COMPLY WI i AL LNON-POINT Issued by: Date
S91! REGULATIONS.RE
Re-roofs
Signature of ApplicanutConuactnr arc
HAZARDOUS MATERIALS DISCL 'URE Type of Roof
Will me applicant or future Wilding Occupant slow or handle bvudous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely
Code.Section 25532(.)7 �/ All roofs shall be inspected prior to any roofing material being installed.
❑Y. 9Nri
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
mit ha'rudous air contaminanu ns d Bncd by the Bay Arca Air Quality Management
all new materials for inspection.
District?
TY. Nn
I have read Oen hazardous matenalampuinemenu under Chapterfi.95 ofthe Cslifor- v
nice Hcalmgr$afcty Cal,S¢mms 25N)5,2TSll and 25530.1umk dndifdc Wilding
doe n0y haw a tenant.and it is my responsibilil m no fy the oecuperm of nen
regi mcnkw ich must he met poor to iemanee of a fi.w f enpaney. Signature of Applicant Date
ori.d agent 11 All roof coverings to be Class "B"or better