05010018 CITY OF
DCUPIERTINO
BUILINGDVIIONSION PFRNIT4CONTRACTQR INFORMAT ��
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Ler -uwiaQ�'� o•nil^>:
BUB.DINO ADDRESS: WATER HEATERS ONLY PERMITNO05010018
21594 CASTLETON ST
'•OWNER'S NAME: PERMIT ISSUE DATE
STEVE IRVING 970 E. MAIN ST, SUITE 200 01 /04 /2009
ONE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECTfSNGINEEN: BUILDING PERMIT INFO -
- BLDG ELECT PLUMB -' MECH
u o 0 LICENSED CONTRACTOR'S DECLARATION Job DOSCT1pt100
y w CC I lottery affirm that 1 son ns
fueed under provisions of Chapur 9(commencing
UW with section 70(10)of Division 3 of the Business and Professions Code.and my license is
,a„ in full forteandef - 37��e7� WATER HEATER REPLACEMENT
Z;: Liccnu Clogs Lick
�`� Dow Contractor
ARFI'S DECI.g.R
I understand my plans M (c uscd.v OdRI' tt/4 _
pWnG `�
u. Lkcnud Professional
OWNER-BUILDER DECLARATION
y 5 I hereby.(Eras Net 1 1. exempt from We Cssion; o License Law for the
p o followwhich
mason.(orm,t W31.5, ,,al ss and ere,durn.fi Code:Any city or county
e
x m which requires a permit re enres t,alar,improve,demolish,fi repair any structure '
y_y pilot m is Tensed p rsuaserequires thovisio s nt Of
wch Permman's Lkanxxle a Law p tatemcm
that be he is licensed purwammthe Provisions of the Comracturil.Tiers law(Chaput9 Sq.FI.Floor Area Valuation
Wyyl o (commencing with Section 7")of Division 3 of the B usiness and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit wbjCM the applicant m a civil penalty of a Occupancy Type
not mmm Nm five hundred dollars(SSW). -- --
❑1,as owner of the property,in my cmplo,cy with wages as their sole compensation. _
will do We work and the&Moore isnot intended or offered for sale(Sea 1044,Business
and Professions Code:The Contractors License taw does our apply m an owner of - Required Inspections
property who buildsmimprows themon,and who doessuch work himselforthrough his - -own employees,provided that such improvements are nmintended or offered for sale.It, _ - - -- •— —
—«-
how.Witer illhaw tingarimprovement ismlEwiid act year or improvtion.theowncr- I�II� I��(I E®
builder wiB haw the burden of proving Nat k did not build err improve for puryo¢of tlllLr II'1f\\�VI'I 11111
alcJ.
❑1,as owner of the property.am exclusively contracting with licensed contractors to
Construct the pmject(Sec.1(144.Business and Professions Code:)The Contractor's U.
one law does not apply to in owner of property who builds or improves thereon,and. /I , .rtOOF•..
who contracts such projects with a eormactogns
s)licensed pursuant u the Contractors AN 20
License Law. .
1 am exempt under Sec. .B&P C far this reason IrL�,y fllf_Ips fpI Iq�\fI,I/r/��
lwncr Data -y(_11-p �,y) � U may(\\�j7 -
WORKER'SCOMPENSATIONDECLARATION , _ _,_._ L4�JU LLtt�Oss V \"
1 hereby arcnn under penalty of perjury oto of We following declarations:
I lac m and will maintain a Certificate of Conscnuoself-insum for Workers Compen-
on.as provided for by Section 3?W of the labor Cade,for Ne perfmomen of thek for which this permit is issued.
I have and will maintain Worker's Compensation Insura ox,as required by SectionOfthe labor Code.for the perfomrsnee of Ne work for which this permit is issued.Workcr' Cnmp�psadlnwrsna Cartier and Policy number sm:rier. miry N..:5 541 r0 IF-0-7 - -
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This auction need not W complemd iTthe Permit is fmonc hundred dollars(Slab
or leas)
1 ani fy that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner sou to become subject to the Workers'Compensation -
laws of Califomia.Dau
Applicant .-,.
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
z foMwith Comply with such provisions or this permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
f-x 1 toothy aMO.that Were is a Construction lending agnuy for the performance of
Z' the work far which this permit is issued(Ser.3097,Co.CJ
[[)0 LendersName
0.. Lender's Address
az
U 0 1 unify Nat 1 haw read this application and state Nat the about information is
it. f" cancer.1 agree to comply with all city and county on insnm and sum laws uladng to
0 U building construction,and hereby authorre representatives of this city w enter upon We
above-mentiuncd property for inspection purposes.
(We)agree to an,indemnify and keep harmless the City of Cupertino against
F" raq liabilities.judgments,costs and a.,.which may in any way accrue against said City
U Z APPLICeUNDERSTANDS of the grecting of APermit.
AND ANTWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR ftEGULA ON
'Al" 5 Re-roofs
p I MOO'TS MATERIALS DISCLOSURE Dau Type of Roof
Will the vpplicant ser future building occupant store or handle Marianas material
az defined by the Cupertino Municipal Code,Chapter 9.11,toil the HcaIN and Safety
otic. 0Yes 15333(x)? 1— All roofs shall be inspected prior to any roofing material being installed.
�Ycs T�Nu
Will the applicant or future building occupant use equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
7�-_�,,
t hazardous air contaminants u dcpncd by the Bay Area Air Quality Management all new materials for inspection.
trict?
❑Yea t�
1havemadthchmaNtmsm=fialsrcquiumcntsunt rChapter6.95of Ne Califon
M.Health&Safety Code,Scetions 25505.25533 and 25534.1 tookoroul that if the Wilding
s not cnvemlyhaw a mmam.that it is my responsibility In notify du acupam of thehe m ire ubemnpriermi yraeOcemi&ateora y SignaNreofApplicant Dale
f y as
Owner or authorized a orl Date All roof coverings to be Class "B"or better