00060157 CITYECUPERTINO
BUIION PERMIT CONTRACTOR INFORMATION:
nlnunnc HOT• WRTF_R INC rI:RMrr NO. 000
60157
OROGRANDE PL .
OWNER'S 2531 GRACELAND AVE APPLICATION06H7 2
I SHOJI AND CAROL
NE` (650) 298-8494 SANIFARYNO. CONTROLNO.
OG ARC]HI ECBUILDING PERMIT'IND)
yHLDO LLEC'1' PLUMB MLCH
�uI'—I L.1 IJ IJ
,Z9
Z S H LICENSED CONTRACTOR'S DECLARATION Job Description
O Z cop 1 heresy infirm Nut I ma Ilecmed under pn......m of Chapter 9(commencing
p_1- wbhS,own7gl0),41a,
son3ofthelm,Il,,ardPmfes,inncnde,ando, wense WATER HEATER REPLACEMENTACEMENT
iinrenrunetsI ell',.
S �S License,Class I.e.x
Dole
Comramr
3 a. ARCHI IIiCl"S DECLARATION
<
I mademm�J my plans shall be used m public tecoN.
x5
❑,O hicenxJ Pm&ssional
OWNER-BUILDER DECLARATION
n 1 thereby uttinn that 1 um exempt O'arn the Clmlractur's License Law lin the
C Z< follnwing a r.(Si3Oiun 9113 S.If us,;sod Pmfessiuns Code:Any,try a rely
p pummatawidenrcynires n e,rmit m ennsvum,nitcr.improve.demolish.in repair any ancone
ment
i3 prions isiswanec,d and to the thovisioconlfac suchpermr's Lic,augneJsmtencm
(comma cingwdpunuann7Nc ofDiiisi n3of heBusu,IslandPrLawon,Cab(Chapter 4 Sq. Ft. Floor Area Valuation
or that he is a wish Sectio"70na ofhe basis 3 of the Business and Pon,Any vi Cable)
or thin he is exempt any cep li and the basis for tbe alleged exemption.Any l violation
of Section]1131.5 is any applicant lino pem,i,subjects the applicant to a civil penalty
of nm smart than E.a nuwrca Iullarx fEstgn ApNE�k��r008. 00 Occupancy Type
01.a.owner A the pmpeny,army mmplayecs with wage'as then solo aompunsatim,.
will do the work•and the.structure is not intended or obered for sale(See.704.
Bu.dnass and Prolesdom Code:The Commit License laws does not apply In an 502 — F I IWDIrP�..10WB-11Mtl6 ENERGY
orr of yropens Y Who build,or imparv, there n,and x hu does.such work himself
through his awn employee..provided that such improvements art not intended or 506 — GAS TEST
ollercd far sale.If,however,the building or improvement is sold within one yea of
impletion,the owner.hudder will have the burden of proving that he did not build or 507 — FINAL PLUMBING
Improve fur purp....of
❑l,as owner olIh p ds.am Exclusivelycontracting licensed I n' u
construct thep 1(See.71H4 business d Professions Cod )The Contractor's
on, u k
/
License Law d t apply, ofproperty who builds or p thereon,
and who contracts for such p j a: itb a contracharts)licensed pursuant to the
ConhmuwuII ti Lou
0 1 am exchipt tinder See,.,H&I�C for this reason
Ouner Due O
WORKER'S COMI'ENSAI ION OLCLARAfION -
I Mrcby affirm under penally of perjuy ane of the Ibllowing decandinns:
J I have and will maintain a Ceni]icale of Consent It,self insure for Worker's
Caagwmation, as provided far by ScOitn 37X1 of IM1e Lahr Code, for the
perfunnance ol'the work for which this permit is issued
❑1 halo anti will unuiamon Wod.m's Cumpc"sntion Insmmmc,its required by Sectiun
379 of,he[.;,hot Gde,for the perimnanae of the wmk on whet this palmi,Is
sued.My Workers Compensation Insurance earrier:md folic}number are: -
Calmer. Pali,Nn:'
CER I'HICATION Or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This NOil.need an he completed if the permit is for ane hn"dmd dollars '
(E II)I»or less.) '
1 eerily that in the pehomunce of the work for vt ieh,his permit is Issued,I
shall not employ any penon in any manner so as to become.subject to the Wmkcrs'
Compensation Lax.of California.Dae
Applicant
NOTICE'I'0 Al-PLICANT:IL aRennaking this Cumficae of lixemption,you should
become subject n,the Worker's Counwnsuln"provisions It the Labor Crile,you must
Q 2 tnnhwith ttnooll,with such provisions ur this sm,il dull be de n od thanked.
F = CONSTRUCTION LENDING AGENCY
a ] I hereby affirm that them is a cousanetion lemling agency for the paformana
of IM1e work for which this Pcrmi,is issued(Sec.3097.Civ.C.)
L10 ❑ Lender's Name
z Larder s Address
U O [lend,the'I have teed 06,applilabl n and.lune than rhe nbuve minm,e,i(sn is
Ls. [.. c...... I;gree m,comply with ell city and county urdmuncm and state laws relating .
U tnh"ildinE,ou,uuc,i,m,and M1sr,thy nmho.1,eopresnnmivestd this city to enter upon
Fry] Ne abmomen,ioned propcny for inrpeaion purposes. `
p, (W'el agree,ome.internal,and keep hamlvw the City of Cupenlno ugaimt - V
y ,liabilitiesjudgments•costs and expenses whichma) in any way aceme illima l said �� r
U Z City in consequence of IM1e granting of Noun
thisr. IC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL+NON-POINT Issued by: Dille
SOURCE REGULATIONS.
Signature Ed Appllc l 'lloncloul D:nu Re-roofs
HAZARDOUS MATERIALS DISCLOSURE -
WIIlhcapplicantorfuturebuildingosccupa,t.store or handle na,arme,nodal Type of Roof
as defined by the Cuper iso Municipal Col Chapter 9.12.and the Health and Safety
Code,Senior 25532(u)7
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
W IbeapplieamorfuinehtlddingoccnpatmeavlNuawthordcvicc>whh'h If,a roof is installed without first obtaining an inspection, I agree to remove
trait huzanlnun a it cnnarninums asdeincd by We Bury Am"Air Quality ME a,count
Divn,C > ❑Nu all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have tend the hazardous materials rcquimnents under Chapter 6.95 of the ,
California Health&Safety Code.Sections 25505.25533 and 25534.1 undcrsm"d that
ifthe building does not curtently have a anent,that it is my responsibility e,notify the
npern of IM1e necuite rears which maa rt he mprior to issnanw of a Cerificac of
°v'see"t,ow" Signature of Applicant Date
Owner or mmthorned.,cut - Date All roof coverings to be Class"B" or better
OFFICE