01070104CITYBUILDING
onEsioNNO
PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
22435 SALEM AV'
WATER HEATERS ONLY
PERMIT NO.
01070104
CH RYLE ARILD
500 AIRPORT BLV
fyPPLlfr NIS 130DQTj
PBONE:
(415)349-3747
SSJAN/ITTARY NO. CONTROL NO.
ZZ ARCHITECTMISGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y
L_J L7 IJ I I
i LICENSED CONTRACTOR'S DECLARATION
JO Description
1 hereby affirm Thal I am licensed under provisions of Chapter 9 (commencing
i
REPLACE WATER HEATER.
with Section 7000) of Division 3othe Business and PromisionsCode, and mylicense
ismfull finmeandeffect.
(40G GAS WATER HEATER.)
u Lianx Class Lic.a
n Dale Contractor
ARCHITECT'S DECLARATION
g 1 understand my plans shall bu used as public records
0 Licensed Professional
y OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
< following reason. (Section 7131.5. Business and Professions Code: Any city or county-
❑ which require a permit to construct. ulmr, improve, demolish, or repair any swclure
ce .prior to its iuuonce, also requires the applicant for such permit o file a signed statement
S PL. FIOOr Area•`<
ValuationO❑
- that hg is l norrocl pursuant to the po,visions orlhe Conlmcuu's License Law(Chapter9
mm
(cueficinBwith ,Semiah]o00)pf Division Jof the BusinesspndRoof essiona Code)
t
I Jas .y' r)% :,�
or data he is exempt thercrram and the basis for the alleged dcmption. Any solution
- of Section 7031.5 by any applicant fees permit subjes. the applicant m a civil penalty
of not mote man eve hundred dollars MNM),
APN Number
l :., .. , Occupancy Type
❑I,as owner of the property, ormy employees with wagesas theirsole compcnis ion,
502 FINAL PLUMBIN
ENERGY
'willdo the we&.'and the su enum is not intended or offered for sale (Sec: ]Bur
The Conlm.rLow 's License w does not apply an
Bushier, and Professions Code n
5 0 6 — GAS TESTRequired Inspections "
owns r of property Who builds or improves thereon, and who does such work himself
507 — FINAL PLUMBING
or through his own employees. provided that such ienscin t no, intended or
� �� �� - -'
'offercJ for Hale"1[fiowevec the building or improvcmcm is sold within one yearof,
sol wi
- � � - - "'- -"-' ' -' �- "- 'Cot ,
completion. the owner Wilder will have the burden of that he did not Wild or
1
eproving
improve for purpose of talent.
prod Y Y connoted, with
❑Lamer ofthe n,am (radio titolicensed
10consum
-"-"_... .. .. .... ..... .. .. ..._
Cher
Business :)Th Contractor
ct the proses lax. 7YL1. (busies andpro Professions Gdea The Co,
�G ®
property who builds ue improves thereon,
License Law docs not apply mon owner hem n,
License
�.S
F L G
with
rL such pfOfeCl< with a, cVnlfaCluni) iC[OYd.pl1r511:1111.10 Ille
and who to tit.
_ ... Y .. ..... _
', Liscls.
Conlm exempt
O ram encmpt under Sec. P•&PC Ponhismovies
..
OCT 11
Dwner Date
" W ""s COMPENSATION DECLARATION
IIhereby offinnunderpenultyorperjuryonenithemilowingdeclaral,mi
BUILDING _
I 1 have tiv ill Linmin a Certificate of Consent Irl self -insure for Worker's
Compcnmlion, as provided for by Seen. 37W of the Labor C«k, for the
perfnnnancc of the work for which Ihis permit is i..wed., i ,
01 hale and will maintain Worker's Compcnsatioli Insurance, as required by. Section
3700 of the Labor Code, for the performance of he work for which oris pernin is
L issued. My Worker's Compensation Ins umna earner and Policy number am:
- Corn. Policy No. ..
;'-CERTIFICATION OF EXEMPTION FROM WORKERS'-
•+ s 'f �''
_w .'• ._ s4.._, --_ COMPENSXHON INSURANCE'."�.. .. �. ...__..
.. _..__.._.._..__. __.._..__.._ .._. _. _... __ ___, ......,. .. ._.
"t finis icenon'need not W completed it the permit is for one hundred dollars
(SLOB .r less.),
s ban fy that the pal announce f m< -k f 1 h tit . pronot's isa. I
_ t, •? '
irwll nal tar plug in, person in any manner su as m become vobject m the. Workers
Compcn Ilion laws of California: Dam
, -
-Applies., . �. .. .... .. - - . ..
_ .. _ _. _.. _ - -_ -
.NOTICETO APPLICANT. It. after making this Certificate of Exemption. you should
t
beci nm subject to the Workers Compensation provisions of the Labor Code, you muss
� fonhwidi comply with cosh pnrvi.dons or this pcnnil shall W Jcemed retakes..-.,.-
1 ""'CONtiTRUCTION LENDING AGENCY
foance
I hereby. affirm that them is a constounion leading agency for the perrm
sof
the work'for which thispermit Issu d (¢cc. 909]. Civ. C.)
Larch's Name'- ........ ... L.... ,.
_ ..... _ _ . .... - ... .._.....__. . _ _ ... . .. ._.._
Lender's Address
+.1 ... Ir"
I Ihm l hove read Ihis application and stale above inbnnmion is
(gree
rat. 1g to comply with all city and county ousts and stale tax's relating
byauthonaemposanmives of this city to enter upon
to con and representatives
�
tronse-mensounion.
per, I
a the aWvc.menennW pn,pttty fur inspection purposes.
(Wel zgree to save; indemnify and keep harmless the Ciry of Cupertino u8ainsl
era
pens which may in any way ace against said
0 liabilities judgments, crisis and exse
q
// ,
- ,Cit,—Q9
: City in consequence of the granting ol'in permit.
APPLICANTpNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
' ',
y' Date
So .,
SOURCE REGULATIONS.';
Sig.awrq urAppljcanocnmmemr,::'' ..`., Dam.-..
Re -roofs
I'AZARDOUS MATERIALS DISCLOSURE
„ Nill lite tip"icant or fumm building ca.,arn soom ix handle hixdNous materhd,
„type of Roof...
.� - ''' •' --'•
ca, definedbyrrite Cupertino Municipal Cale, Chapmr.9.12aml the Health and Safety
- v.f '• `
•• •.e r'•
C'le, Section
<n on 255320 1. "
IYo3 0 No ' r
t r
-All roofs.shall be Inspected prior to any roofing material being installed.
11W01the applicant future building execpant use cq p I d which
If a roof is installed without first obtaining an inspection, I agree.to remove
6 emtWound.,areunm .ants as defnd by the Bay Are Air Quality Mawge.nt
O Inez`
all new materials for inspection.,, Applicant,understands and will comply with
- : Ives mNo' - - - -
�musnal.s
all non -point source regulations:I.
have read She haiardaus mquiremenls under Chapter 6.95 of the
r
California Health & Safety Code. Sections 25505, 25533 and 25531, 1 understood that
if the building does not currently have at cram. that it is mvresponsihility to notify the-
occupml or the requirements which musttan prior a issuance of a Certificate of
,W
Oce.'ney. ;
Signature of Applicant _ Date
All roof Coverings to be Class "B" or better
Gwaeroratomonaedaeept Date
. ... _ OFFICE