01020099 CITY OF,CUPERTINO
autLotNc DIVISION' PERMIT CONTRACTOR INFORMAl'ION .'
BUILDINGADDRESS: PERMIT NO. • ,
21.593 CASTLETON ST; '' WATER HEATERS ONLY 01.020099 '
OWNER'S NAME: - t - j APPLICATION SUB DATE. '
JERBIC CHRIS C, ET AL, 500 AIRPORT BI_V . . 02/20/2001
PHONE: SANITARY NO. CONTROL NO .
(415) 349-37t47
p K Z ARCH]FEC'FIHNGINEER: '. BUILDING PERMIT INF(,
BLDG ELECT PLUMB MI CH
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ll 'LJ
Z S y'z LICENSED CONTRACTOR'S DECLARATION Job Description -
1 hereby affirm that I umiicaitmd under prdait ical of Charter (commencing
GZ54 with Section 700(holprovision 3ef0a❑ .: dP f '. Cd onlmylcese
is' rich f J ff I. s
E. a Li secl... L x' REPLACE 50 GALLON WATER `HEATER
O U Dal Contrast... H
w 3 u y ARCHITECT'S DECLARATION- -
C�to l understand my plu s daull he.,d as public wro al,
edLicensed - .. z.
a.,
p0 P f al
OWNER-BUILDER DECLARATION t _ i
m 1 reach,reason.
affirm the 11. exempt from the Cnmract n e A ac Law 0 for the
following .IS i 90115 B JP F:' 'C d e Y an unary ,w x' •� � p
ae which requires a p t l 11 p n do I' p Y structure
'a Li t t''' '1requirestl ppI II hp a is :L 1' aometl ' .• .
`tell licensed v n 0 p a n3 rho tat r 1 L (ChapIr Sq,Ft Floor Area Valuation
or el som,lwith Section7000) Div msI theSten .andmfAnyvi Cade) , ,
or the he 7 exempt Iha, ppl and he basis f the ri,the pplic.ac,Any violation_
of seainn7R315 by any epplicom!npamtit su6wl.the uppllrnm tovdvilpwvlry
nrnatn,aremanrvelwtmreedmters($son). e,, :APNNumber • Occupancy Type_
❑htas�whernnhe Pntpenn..r my empl..yee,wiin v-�e�a,meo-.me ca�ml,oasndnn, ^c will do Nwork,and ill .t I t tolerated-, rfrdf Pi 7044
Basin...add Pr fess'nns Code:The Corrector's actors Eben...L w does ,at apply tont t Required Inspections -
r of property Who builds or lmpves therm..,and who does'such work himself
or'thm
rough hi,own employees(provided that sm it Improvements are no(imenled'n' t "mss-,' 502 — FINAL PLUMBING` ENERGY
urfcrce ror at,,If,however,the building or Improvemmat is sold within one year of
complebon,the ownernailderwillhavethehardsoofprovingthathedid notbuildor 50E GAS TEST
bod"we far pamnxa(of,me'r .-. -
olasawtmotmep pry. s Inr a rima...... 507, — FINAL -PLUMB'ING,.
construct tire p j i(Sce,7044 H d Profession,C I )The C rhaob r r .
License Leavens,no, pdy loan owner LPropertywho b Id imphods ffi,osaa.and who coartrwabforh projects with nameam s) licensed parmount t the -
Cintruncours,License
La. .
���
❑1 enptenLH&I Cfnr N4 non - Lea
Owner t Date. 't •oer .
WORKER'S COMPENSATION DECLARATION •t ..,2001
Ihcrcby ofOrm under penalty of paijury one of the following dedanainns: - +t
-'❑ 1base and will ant T' .Caubficat,orConsent 1. 'elf-in for W kes -
.Compensation as provided for by Section 3700 or the Lhm Code, for the G' -
performance of thework for which itis wem r is issued 4 s d BUILDING
I have and will met am Worker's Cotn,maiion hatio ce,tts retryiced hyo S,'Iran °'°•' _ _ -_ --
3700 of the Lah.,Cade,for the parformanec of the work for which this Permit is -
issued.My Workers Compensation Insurance carrier and Pnllcy nitirber are _
Carrier: Poll,N"L
ice .CHIC IFICA'I'ION OF EXEMPTION 17ROM WORKERS'
COMPENSATION INSURANCE
(This section octal a.,ti e nnplele I if h ,aamil i,ounce hundred dallnrs
I certify that in It,,Pero nnured of the work for which this pe mil is isoueJ.1 - 4 �-
e.hu0 n..l employ any poll...1 in any manner so as to accome xaffect to the W..star,'
Cona,smabo.L.-m Califmnia.Data
- - - -
Applicant { '
NOTICE TO APPLICANT:ICANT 11 air making this Certificate of Exemption,you should
Z become object i,Workers,C p i fl I'd Lahor Cole,yot minor -
1
Forthwith ...only with 1 r 'onvo this pItr II heAeemuJ evokedQ
rY -
F V� CONha RUCTION I ENDI NC AGENCY
j1NaaEysffimrthra hare scammuctionI gvgencyfor the nednrnwna s ,
,W otitic workf h'ch this pint's icsu d(SwcL 3107.Cil.C.)
..� Q Led N e
z Lead 'Address
tri a
C.) C 1 cenify that l have mad thise,laulacto ad one.Our the area Wommfmi.s b' _
Pk �.t cancel.1 agree to comply with all city and County ordinances and state laws relating -
0 [) rolumicho,etura,morlion,and herchy vcriterion representatives ofihs city to enter spot .. or - -
'y,ky
the h eme liand propertyr inspection purposes,
•.' t
Fy Qt (W) save,anclearmil'yandk pha'ntlassthe C'rydCapermo.,rarI
tr V1 liabilities imlluallon,cost,.,to stresses which may in any way accrue oga'xa-aid
C.) z City in consequence al the F,mnfng or this permit. .. .
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITHALLNON-POINT aissued. "�' H ',Date 1.
t SOURCE.REGULATIONS, - Y•
Signahare bfAppLtme/Cottracmr 'Dee•. Re-roofs
' HAZARDOUS MATERIALS DISCLOSURE - '
Nil fie oPPl c m combine Interim, 'pi t rainvothandlebroackar,matenal •Type of Roof -
acdefined by the Cupen'no Municipal Code.Chapter j 12,andilic Ilc.dth and'yIncly _ "r
`Code.Section 25532(vlp
eve,. ,.o N.. - All roofs shall be inspected prior to.any roofing'material being installed.
win o ppr �_ r b w g a n t w n I I o n If a roof is installed without first obtaining an inspection,I agree to remove
. arch. d sair cat ri as contact by theBuy Arca Ali Quality Menagcmen
District) „ all new materials for inspection. Applicant understands and will comply with
Dye - °N ' .all non point source regulations. ' W
•�. Ilave read theh d 'mmodelf° -
y o f 4.1 a fi man d t h t
Calf ia Irl , Solely Coda avec* am,th that
J25514 il d a'nd that .;
iftl bold tgdoes mements ly whrhlr most
be and prig to sresponsibilitytonolTy the J
acct pane of the requirements h' hmustb and rte i, unc din Certificate(of :^
Omupancy - - -
' '- SignamreofApp]Icantr � - - Date -
Owtd,as scan-ed agent Done., All, roof coverings to be Class "B”or better r
as OFFICE