00100014 `CITY OF CUPERTINO " e' " " '
BUILDING Drv,SioN pER1VIIT, CONTRACTOR'INFORIVIATION:
BUILDINGADDRESS: + .� � - >, + n PERMUNO
2 .CT `. r'. .- '',WATER HEATERS & MOR7 :PLBG.I0010eBa1,4 '. l� .
' OWNER tiNAME: ._t' + • " APPLICATION SUB DAI C
I.
WFTT7hiiANNoARTH
I LAND Its ANCY, J' ' '1163 .CHESS'.DRIVE; S 1ITE-''KI.0/03/2000 .
PHONE:. - 'r - ' - SANITARY NO, " CONTROL NO
(650): 522-9287,
O O ARCHITECT/ENGINEER - , _ "f BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH -
w n ' hICf.NSLI>CONTRACTORS DECLARATION - p
Cz c da a p rcnpt 9tenne g 'Job Descriptio
m lh Sect' 9a1N1) fD' 3 flKe Bu IP f,'o C d d nyl'
to EJ I:' rllf Irfel 1
pX,xw.a u,turw Cin,,. :REPLACE, 50 GALLON WATER _HEATER' ^, .
rX C U Dnle c about., •• .of
,AIiCHITEcr S DECLARATION
•�5 w - I nativist I mY pl ,'shall be ii,tal.,puldhe mccans
y O O 1:cc sed Pmreslmod '
k ^'a
°J o OWNER BUIER DFCI ARAI ION - ,
u7v, 1 thereby
a S3[30 yp pr h i aft rtn I,,I"n ee theC I L ; L traffic loll oA (Section9135ctrms andProfession,Cd An, a tY
h require, P m ll C eI t 1 p e Lh poy mm
,gJ'I warnil 1
ik
lxmile
hillen tt P att1 1 (Chapter 9 Sq. Ft. FloorArea Valuation t,m 6 with Sect 9000) f Do 3 f d Bas au d P o,s .,Code) v
l i
,
orthe,h a thembnor saildre.basis. l thealleged epa "AY lairme - '$0
,.
.or Sewn 90315 b,anyppl' mfor a pc "n,umira,the app) to a all penalty
nrnm roam than fivehundred doll.,(s500).. . .APNNumber _ - OccupancyType -
❑I work, t erm s to wimxo
wall d IM1 k o 0a,structure :p i mended e e L d for sal (S 91144 "
Bn, dP r, to Code The Contractor,Llhdn so d Irk human r Required Inspections
x f p ph ry en n ec improve,IM1 d h e 1 k intended
csl ' ^
.„a foram -ply the provided n improvements l t year or 5x2.,— FINRL-PLUMBING,-'ENEI
comoffepletion,
ul ion,the if ho hold the lIsivebuildingimprovement rovin Id he handid nuc ywr or _ - r
nmplatn,n,me owner-bailaer will bare ale seen nrnrnring that he die not build or .506 'GAS 'TEST
improve roe Purpose of sada). _ " ..- +--.vy,I , ..bs '.
907. -' FINRL PLUMPING
is
01 a,owneroflhc Pn pent un exchis ly nraainy wl161' 'd eonwem-t ;f _ ..
con„mm me protea(Sec.9044,Buslttass tad Profe,. e,,anCode:p The Cnmfnmor's '. -e
Lice: 1 d not apply t an 'his of pP ty -h land - p the ” .f'+' .,
ranA ,no commentfar inch projects wiN t' I (.)1' d p at m the S _
y.
Contractor Liters,Lw h a +
❑1 no,crumqu madt,r Sec ,B&PCf this onson
Owner Date sI r
le WORKER S COMPENSATION DFCL ARAI ION "
I hereby affiric underpenalty lly t perjury one of0 following d 1 "I
�011 + 1 will anartalo.Cell 1 rC . ii If f W k
Cmmpamsatimn, as provided t by Section 3700 of-the Lahm.Cmli, for thep r '
,perforations,of the workf..which this p t :'..0 J t 'f] .
❑1 have and ,It ma nt Workers Ccahwhoution Insurance,as required by Section
3700 of the Luhor Cafe,far the perforntonce of the work for which this knot is
t
;sued.My'Worker's Compensation Insurance eurticr tntl.Prilihy number are: ' ,
- i ts,
Carrier: Policy Nn.'.
CERTTFICATIONOF EXEMPTION FROM WORKERS'. - - 1 a
5:, COMPENSATION INSURANCE.
(Tin section need not be completed if the P tis ma one hrandacd dollar, + _
Ieri den inth Inerme,we Mlle k'fr whichlh pention,".sudl _
shall not employ any piavien in any mann m became uiIqcrr,mEc W..orm
Compensation Law,of California Dae - -
.i " Applicant e '.
NOI ICL IOAPPLICANT
,O Oheeomceuhjecl to theN k C p vat nP v ns nr lh I b C J y u .t
forth ih-rnnply xnh acM1 prnvis non or lht,perntsht 11 betl nod rcvnked . 7 ' -
-'^ CONSTRUCTION LENDING AGENCY F'
an� 1 hereby affirm that Ili re . construction lending agency r the performance
fine work for which thispermit s sr ad(Sec 3097C"v C) - h " .) t
a Lenders Name
Z- Lendrs'Adam,
t.
I cornyfair il 'd Ili ' d athat lwes b information
tlate
- t
(~ orr 1 I. 6 1 ply tM1"11 ly IY I tYtdt' d t t I 11 g . -
C) thea to g '1 l dl by In P tt M1h etymaucrupa
IM1c+b `
[� el dP petyf f P M: - - - "
I,y a (We)agreet e 1 fy dk Iunatics,theCity
wa fC p a against y, _": e ,
+y lianil l 1 dg e o sl d p u.which "Y a any way 'quina 1 :a
U 7�. etr adeynrnhe Deer fishing of ibis permit., �
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS - ISS, y:- iWte
signatam of ApplicarrUConhncter .• :Date i Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Will the app)east future haddho,ocaustlt,mre ar handle ib',mdoa,rramairj" '. T e of Roof
a,refined by the Cupertino Municipal Code Chirpier 9.12 and the health rid Safety yP,,
Oodc 6 f n 25532(x) ,` ��.' f� .. ry r
°Y DN - All roofs shall be inspected prior to"any roofing'material being Installed.
will the i 1 n w" s occupant use equipment ordevaces'which If.a roof is'installe'd without first obtaining an irispection;I agree to remove
emit h dial v}eon[ m nL is defined by the Be,Arca A Quality Management
District^ a .. all new materials for inspeciion:'Applicant understands,and.will comply with
❑Yei ,.❑No ."�
't o'sall n_on-point source regulations.. '`
1 brave mad the hazardous m nen N requtrcicas underChapter 6.95 or the, - _ I - -
bhf H bl Cycle,S I ,.-25505 25533 and 255311 de lad that' e -
�ifthe budd'ngdoesnot c mad,have aeraanl that ts my re,Ponsbd"lyto lorry the W• + n
_
occupant pf the god nn t. which must fourth Prior it,ass f.Conunnav f. 1
, Signature of Applicant ',.•: +' ' ,, Date.
r. -
I
ou,nc,nraatnorxcdagnnl . • Date _ 'All roof coverings to be.Class'`B"or better:
OFFICE ..
,