01020093 CITY OF CUPERTINO CONTRACTOR INFORMATION:.
BUILDING DIVISION . PERMIT /
PERMIT NO. V
BUILDING ADDRESS
• } il(>T nThIC1.111DTL1- ny 3�CT L'mTC_` mL�T�_ Thl:-..r—c i.0cctonc,
OWNER'S NAME - APPLICATION SUB DATE
>.–l!^rn"•,'a .T.`ZI'".?=3 T ET I'1L }7 —T..,nlnrr:^nom,:,-n6 !lllc
ONE SANITARY NO t` NTROL D.
iZ-:3: 22'33 7201
s Z ARCHITECpIENGINEER;
BUILDING PERMIT INFO
O OF - BLDG ELECT PLUMB MECH
aZ:
S ti LICENSED CONTRACTOR'S DECLARATION � Job Description '
,Z". I h,u by nmrm that Into bcemcd nndcr plovl+lam of Cmpm,a ammnenc:% Is ,
-¢O,F'. wnb Serum 70(shat Dlol+ma l nl the III...rns and lhule+snms CuteMuni,heenw ' ,
°•e z 6 License Cloa,and effect Lac A , '
ti06
Date eentmner REPLACE 40 GALLON GAS WATER HEATER
3 n b- ARCI11 CECr'S DECLARATION - -
!'i=O I understand my plans shall be reed as pnbim mv.ol,
E o OWNER BUILDE R DECLARAI ION
[a 1 hems""from that I all exempt from she Contractor's License 4tw for the ,
h a following reason (Section 7031.5,Business and Prrfe+so m,Code Any city or county -
Y S G xhmh requires a perms to cunswn,alter,improve,demolish,or repair uny+trucwm
63CQ prior to its issuance,also reclaims the applmant tot uch permit file a signed Gatement
,bar he.+licensed pmsamIn he pooloon,of the Curiosities Li,em<eL,w(Couple,9 . Sq. Ft.'FloorArea Valuation
mommrncing wnh Section 7sN0 ul DI1,Q n 3 of the Bmmew and Prola+von+Code) -
n.than he is exempt thnerom and be basis ar the allcgvd r.mn,nun-Any lamas""
n1 Swom 7031.5 by any apploaml Inn,perm",uhRV t+Roe nppbcan,to a nod penal"
nrnat mom than rive hundred danam.u50(I APNNumber ' Occupan
0 1,asaxncrafthe propeny.ormy employees was vs.,,l stheir,adve upensation.Will do me work,and the structure is not intended or offered for sale(Sec.]BM, - — 3tr=b40 @ru 1 t q"6`i
Rusmce,and Porm,siam Code"11m Coppactnr',Lmcr+c law does not apply to an RegUlred Inspections
six r of property Who M1Wds ar improves therein,and who does such work hhn,elf
r Innmgh I..+oxn etnp o,,,,; inn,deJ that n,.,h inpmvenienfs arc....I ism"Jed or ,
offered or sale II.ouseven the budding or nnpnwenent I, old xi(h,n one ar of •502 — FINAL PLUMBING ENERGY
completion,purpose of sale) x.11 have the buNeu al pnn'.ng that he did Sat build or 505 — GAS TEST '
tmpmve for PuHxs+e of,ale) +
❑I,is awes"o]the I..19, 111u.sloole"cnn(ranng xath hecrad limitations or, 507 — FINAL PLUMBING
aomwct the pm eel(Sec.7044,Bmme,s and Pmlexmrs Cash,)The Connector's
Luer+e I,aw does ur ,,l l to tin uxne,of pwpcdy who ) mr sir.I ou thereon, .
.and who us due, fur sock project+wnh a cnm.:mdml+) i d,meA'punu"nt in the
Contrti hireme Law' ,
❑lam exempt ender Se B&P C tar this seven
Oxoer Darn
WORKER'S CUA1PIib,SA'I'ION DECLARATION G/
I hereby"flies"under PcnahY nl penury ones ul the following Jed.v:ninth
I 1 hale slid off mamma.. r Certificate of Conan( u, +,If.....I far Worker's !
Compen,auon, as presided far by Section y]q) of the Lhor Cole, fur the - /• +
' performencc of lM1e work for xhi<h(lies pcmtn t+iswal � '
❑1 have and will maintain Wo,cr's Cum'doolion Inami ,as required by Seven '
lief)of the I.,for Code,Inn the P111unnanen of the wok for whmh thus pemmt'.s
ucd My Wororr'+Compcn+al.n I h,roulle carrier and Popp numh"r are' . ^
Carrier Policy No, '
CERt'IFICATION OF EXEMPTION FROM WORKERS' -.
COMPENSATION INSURANCE.
ITlu+section need not be cronplemil If the Iwcrmn Is for one htmdmJ dollars
I$100)n.fins) -
I certtty that in he felt omi...me of the work tor whuh this pronto is issued.1 "
shall not employ any soom in any manner m as tit secure subject to the Workers'
C..I,n,.t a U.,of Calif..,. Dare
Applicant
NOTICETO APPLICANT If.ul(er nmk.ng(lire Crn.rca(e of Exempunn,you shnold
M1eaime mblcci w.he WnrAer'e Cnmpcnsmum Pnrvis.nn+of the Lahor G,Je,you.nun
OO fonhxnh n,.nply wish melt pr,ko ns at this pcmth shall be helped monked,.,
(/y CONS'(RUCI ON LENDING A017NCY '
� > I hereby affirm IN,there,,comtiurtnn lending agency fur the pertunmanee s '
of me work for whmh this"oil Is.....d(See YN7,Cs C.)
11 A Under's Name
5 z Lender',Address
UFO+ Ieeody than l have read lh.supphnan.n,:.nl+('m than me:mnec.nI.......I n.+ ,
rood I agree e,comply sink ill city and county ordinances and stmt law+rehtmg
t.7 to bn.ldmg cunantnion,and heresy umhnnec rcprc+enmuve+nFthis v."wester upon ,
the 'u'rty Io m"t,...purpua,
176 (We,nitrite to save.indemnify and lecp barmle+s the City of California against s
In liabilities,rydgraems,costs and expenses which may in any silly actual,against said
U .zi O"in cnnw,ryence of the 6nortin,of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ^ Date -
SOURCE RECIULATIONS. Y• - -
SimulateofAppfitaMConnacmr Date Re-roofs
x'dlthe app)HaZARIU..m buds ng MATERIALS DISCLOSURE, su up andle th—fdo smarrall Type of Roof ' '
as defined by the Copeni..Municipal Code,Chapter o 12.and the Halm and Safety
Came.Senian 2551200il
FJ Ye" - clo All roofs shall be inspected prior to any roofing material being installed.
W.Il the upphcanl sir larum his Imn,......m nse egmpmenfo,dnvme,x hI,h If a roof is installed without first obtaining an inspection, I agree to remove
inn ha<arJom air crnmminenn e,defined by the Buy Area Air Quality Management
is . . all new materials for inspection. Applicant understands and wilt comply with
OYe+ °No all non-point source regulations.
I lime rc:W the hakdam mmenals reyuiremcm+under Cltapu.•r.f.95 of(he r. '
Cnldemia If"11h&SAll,Code,Semmo,25505,25533.mJ25534 1 midcnund thus ,
if the In dmgdeer, no enncdey have,craft,that it is lily re+pon+md'my to notify the ,
awpant of the requirements xItch mire be met prior."issuance of a CeniErate at
Ocra aney' - Signature of Applicant - Date,
Ox ner or atimon.ed agent . ,Date All rooficoverings to be Class'"B" or btter.
'OFFICE