01020109 cr TY OF c DreeONNo 'PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO. i
ONLY 010201.09
OWNER'S NAME: APPLICATION SUB DATE
02120/2001
PHONE: SANITARY NO. - CONTROL NO.
H O
woo BUILDING PERMIT INFO
'FC1 BLDG ELECT PLUMB MECH
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Z O LICENSED'CONTRACTOR'S DECLARATION Job Description
0 Z y_ 1 hereby affirm that I am licensed under provisions rf Chvpwr9(commencing t
with Section 7000),dDivision 3 fthe Business and Professions Cale,and my license
is in full have and effect.
rca excess rlasw Lm.d REPLACE 50 GALLON GAS WATER HEATER
0 dO Date Common, .
a G ARCHITECT'S DECLARATION
ONS 1 understand my plain shall rte used as public records
p O Licensed Professional ,
OWNER-BUILDER DECLARATION - -
1 hereby aftian that 1 am exempt from the Contractor's License Law lar the
fialliviing reason,(Section 7031.5.Business and Professions C d AnY city or county -
$x p
which requires a permit command,ah P demolish,or rep y structure
t°6d3 w
primitive;issuance,aI. t tM1 ppf oa fistrimchpeamn file ami,insdimarmem
AM he is licamiPetulant tn p f the Contractors License Law(Chapter9 ^ Sq. FL Floor Area Valuation
(commencing with Section]01101 of Divis o t 3 of the Business and Proles.ass Code)
or that he is exempt therefrom and Ise basis for the alleged exemption.Any violation
of Section 7031.5 by any npplicmn for a proud wunjens the applicant to a civil Finally
of net more that five Itm,dred dnlmra($5010 APN Number', Occupancy Type
❑I,as owner of the property,or my employees with wages'as their sole compensation22
00
will da the work,and the structure is nm intended or offered for sole(Sec.7(N4, - - -
Business And Professions Code:The Comraemrs Liccux Law draw mil apply or an - Required Inspections -
orr of property Who huiMs or improves Thereon,and who does such work himself
Through his own employees,provided that such improvements arc not intended or 502 — FINAL PLUMBING ENERGY•
offered for sale.If,roves r,the building nr improvement issold within one year of
completion.the owner-builder will have the burden of proving that he did not build or 506 — GAS TEST
improve for purrybe of sale.). - -
❑1,as owner of the property,Am"Clabvely contuoting wan licensed contractors to 507 — FINAL PLUMBING
ci ndruct the project(See.7194,Business and Professions Cods.)The Cormorant,'
License Inst does not Apply to un Avner of property who builds or improves thereon,
and who contracts for such projects with u comruanr(s) licensed pursuant to the '
Co newbars License Law.-
❑1 am exempt under Sec. ,B&P C for this reason
Owner - Dato -
WORKER'S COMPENSA'T'ION DECLARATION ,
I hcmhy oftirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Ceaificate of Consent to w•If-insum for Worker's
Compensation, as provided for by Section 3700 of the Labor Cede, for the
Fetfnnn:mee of IM work for which this permit is issued.
111 have and will maintain Worker's Compensation lnwmnce,a-required by Section
37W of the Labor Cale,for the performance of the work for which This permit is
wed.My Worker's Can lemortion ommume Mair,and Policy number arc:,,
Cartier. - Policy No.: - -
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
Cor,xenon need not be completed if the permit is for one hundred dollars -
(Shall less) - '
I certify Nat in the perfnAny AvA t the wort for which this tt in,the
issued.'
shall not employ any person in any manner so m m M1mmme suM1jem mi the Wnrkern' _
Compensation Laws of Culiforninn.UareAppl ,
NOTICE
NOTICE TO APPLICANT.IL offer matins this Certificateof the
Exemption,you should
became sa ourrid to the Workers Cumns or
prov shall
of the Labor Conde,you sins
Q•O forthwith comply with such provisions or This prmit shall h IcnneJ ruwkcd.
z.
f" ti CONSTRUCTION LENDING AGENCY
> 1 hereby which
this thcnb is n anted(Sec. lending agency for the perfitrmunce
!r7 of the wort for which Nis permit is issued(Sec.JIY)],Civ.CJ
0.. Q Lenders Nome
a Z Lender's Address -
I crafty Thar l have read this vpfilicrawn and.,are that the above nutrlmation is
F. correct.I agree to comply with all city and county ordinances and state laws relating
Q C.)
to building commaction,and hereby authorise representatives of this city to enterurysn
(y] Ise above-mentioned property for....P nn pupnws. . ,
. 4 (We)agree to save,indemnify and keep harmless the City of Cupertino against '
VJ liabilities,judgments,cons and expenses which may in any way acme against said -
T..) Z City in mew"m mo of the gnantirg of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. - Y'
Signature rf Applivan(Contiocon - Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or fuwm Molding as upam stun or herons haaNtms maedol Type of Roof
as defined by Ila Cupertino Municipal Code,Cbupicr 9.12,and the Hetlth And Safety
Crile,Section 25332(o)l
°Yei 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occurpront use ethrionount tit devices vd,,li If a roof is installed without first obtaining an inspection, I agree to remove
'coal hmallous air contaminants as defined by the Bay Area Air Quality Management
Dinrieb Yea ❑Nn all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have read the hmsrdii materials requimments under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534.1 understand that
if the Wilding does notcurenlly have it lenanl,thin It is my m,pomsibilily In notify the
occupant of the berammenes;which must W met prior to issuance of v Certificate of
Occupancy.
Signature of Applicant! Date -
owner arauthodsedagent - Date All roof coverings to be Class `B" or better
OFFICE