00100213 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IAJILDING AUURESS:
PERMI'I'No.
I
OWNER'S NAME APPLICATION SUB DATE
II /
ZONE: SANITARY NO. CONTROL NO.
Q O o ARCHITEC'UENGINEER: _ 299-24-94—
- - BUILDING PERM]I'INFO
a 0— HLDG ELECT PLUMB MECH
N f=1 LI IJ
LICISNSED CONTRACT'OR'S DECI.ARAI'ION Job Description
a y— I hereby arfoathat I am licensed under provisions of Chapter 9(commencing
F=-
� with Section7(XXB of Diokinn 3ufthe Buxincss and Profe,omm Cnde.endmy license
is in fill fora.and clTee.
L.iren,e Class Lic,it
x 5 LL v Date Contractor
:Y o ARCHI'rECr'S DECLARATION REPLACE WATER HEATER
u,
F—0 1 understand my plans.hall be used as public records
Y
i p O Liamsed Rofcvsionnl
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' 'WBUI r DECLARATION
= I greasy.pure that am exempt nim the Contractor s :Anyc law for the
C Z a following reason.(Section]onstr.Business and ver de roti Calc:Any city or 11rounry
$.2 p which requires a permit u:construct,(cher,improve.Acmolish,or rcpvir any slmcture
prlunuiaivxuuna,also rcyui:as thcupplicam f Counterm's lAwnse lsesdaatcmcm
(cathmecial,with unarm 700 pnry ivisin 3o Gemuinra Llan lawlCLCpar9
(nsmmencing with Section 700B of Division 3nf the lsusinds anJ PndessiunaCde) Sq. Ft. Floor Area Valuation
it,that he is ammpt therefrom and the basis for the alleged exemption.Any violation
of Section 703 15 by any applicant for a p•cur uhieor the applicant m u civil pamill,
ormlmore than five hamlreddollar,fSAIDI. APN Number OCcupT36ape
❑,,downer ofk.,ad he may rtisa.,i intended
or smnc�iradec Vice.
will do he work,and the ode T e is not clor',Li or License Law
sew for sale(l,,I ],,a.
chimes:renpint x,inmrild-o Thenove,imx,.lanalawdare,notappl ynnan yuired Inspections
r ulpropaty who sonar m iovnmvn...suchn..h.,d whn dn,are a work Idmnalf 31637023.
control
eyed foliate.
own cmpinyees. Wilding
teat such impnnenonls are non intended or
somple for sale.If.hmssven,he budding e l"den Of pros is what within nor year or
inm as,kadmnwne-,under will n:we one Horden of rmxmg that he did dm band n, 502 — FINAL PLUMBING ENERGY
mpmvc for purpose of solo.),
❑I.avower,ofheprnperty,all,exnn.ivrlycontmctingn;InBweaved common„m 506 — GAS TEST
store the o(Seel lila.Business.sena property
whops Q,JcJ The Contractors 507 — FINAL PLUMBING
License Law coca ro not apply h,air owner ,papery won Wilds or iThe Ca thereon.'
Cnit who comedy(or such prolms with a coumcnn(s) licensed parouant to the
ontrrlonI Lino,law.
❑1 am exempt under Sec. .B A 1'C for this reason /
Owner Ilene
WORKER'S COMPENSATION DECLARATION /
Ihetuny aftinn ander penaly uflxrjury one of the following dcelanviunn:
.] 1 have unit will maintain a Ceoltleme of Consent to sel6{dure for Worker'.
Con:penwtiun.,as provided for by Sectio, 37I11 of the Labor Cook, for the
—1 oolleer of the work I'o,which this wrinut is issued,
❑1 have and will mainain PWrkc,,Compensation Insurance,as requited by Section
3700 of the Labor Code,far the pMtmmance of the work for which his pearl,is
>unl.My Workers Colopcdutlon Insurance carder and Policy"anther are:
Carrier; Policy No.:
CI;KIIFICA'1'ION OF I13EMBTION FROM WORK,?RS'
COMPENSATION INSURANCE
1'I'bir section nerd not becm:g+lered if the peanut is for one handled dollars
SI W)or lay.,
I verily that in he perfumorme of the walk fur which his Penh is issued.I
,hall nut employ any person in any mange,so as to become subiect to the Workers'
Comq,errmlon Luws of Callfurni t.Dalc
Applicant
NOTICE TO APPLICANT.If.ape narking this Certificate or Exe tptinn,you should
berome subject to the W'orker's Comprmotion provisions of the IaWr Code,you must
OforM1with cnattily with such provdom or this Iem,it shell be deemed mvnked.
Z _z) CONS"TRUCI'ION LENDING AGENCY
I hereby alarm that them isto codBuction lending agency for the performance
kat of the walk far which this permit is issued(Sea.3197.Civ.C.)
LSs Q Leiner',Nano
Z I,cnacr'x Aadresr
U I certify that l have read this application and state that he above information is
4. E. eirect.I agree to comply with all city and county oNrources aW state laws relating
huilding codaudion,and herchyaahave reprcaenalives of his city to enter upon
the aMwcmantin tell property I"or inapt Linn purposes.
tr„ y (We)agree mies ,indemnify and keep hamkas the City or Cuperinn ogaidl
h liabilities.Judgment,costs and exprices which may in any way araoe against said
U z City in consequence of the granting Of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY Wo11 ALL NON410I1oT Issued by: Date
SOURCE REGULA'T'IONS. y'
Sigtamrcof AppfiearUCom.vua nor Re-roofs
HALAROOUS MAI ERIAI S DISCLOSURE
W:pmc;hppliranmtritium mliming:„eupnmatorenrIradlehrmadodmatcdal Type of Roof
Its dcfmmd by the Cupcnlln,Mmargnl Code,Chgnc,9.12,ata,'he health and Surety
Cloo Section 25553200
0 ye, 0 N All roofs Shall be inspected prior to any roofing material being installed.
Will tbeapphe:I:Itmmtmestdldlagoccupant use rquipencetmdevweswrOb If a roof is installed without first obtaining an inspection, I agree to remove
nllt luoardnav sir conunnin:anv r Irlined by the tiny Aire An Quality Management -
ianmL all new materials for inspection. Applicant understands and will comply with
❑Yes 0 N all non-point source regulations.
I have read the haeardnd materials reluimnmnts under Chapter 6,95 of the
California Health k Slily Code,Sections 25515,25533 coat 25534.I undcwl Lard that
it the building dorsnnl currently have a mom,that it is my m%,mr6hil'ny In notify the
tceupw ser the requirements which mast be met prior to issuance of a Cerifcate of
Overrun, Signature of Applicant Date
Owner nr authorized agent Data All roof coverings to be Class 'B” or better
OFFICE