03020019 CITY OF CUPER'1'INO4W
'
BUILDING DIVISION
PERMIT CONTRWOTO.WINFORMATIOM ,,
BUIL DING ADDRESS: HOT WATER INC PERMITNO.
20171 JOHN DR 0-1020019
NER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
FURUSHO WALTER K TRUSTEE 02 06 2003
ONE. (650) 298-8494 SANITARY NO. CONTROL NO.
ARCH] ECTIENGINEF:R: BUILDING PERMri'INFO
BI.DG ELECT PLUMB MECH
0 0 o
w00 LICENSED CONTRACTORS DECLARATION
ce 1 P l hereby affirm that 1 am Iianwd ander provisions of chapter 9(commencing Job Description
a
Z. wiNSuction]OMIpof Division Softhe Busirrcss and Pmfcssinaz Cak,anJ myliacnsc is ������®
,_�y NfrBlarecandc ec 7 �� REPLACE WATER HEATER
i O'Q? License Class Lie M
O=—o Date CantacFEB 2 5 2003
ARCIIITE(TSrDECLARATIONcta
a I unticrsand my plans shall M used ns public rmnNs
�3au
N=0� LiccnuJ Pmfcziional
f�is OWNER BUILDER DECLARATION BUILDING
ad a Z 1 hereby affirm that 1 am exempt from Ne Contractor's License Law for the
a a OO following reason.(Section 7031.5,Business and Professions Code:Any city Or county
w2� which requires)a permit Or enetrucl.after.improv.demolish,or repair any structure
priits is mance,also requires the applicant for such .it Glc a signed statemnte
ISGor m that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area1®1100
rc� (commencing with Section 7000)Of Division 3 of the Business and professions Code)or
a 3$ that he is exempt therefrom tied the basis for Ne alleged exemption.Any violation of
Section?031.5 by any applicant for a permit subjects the applicant to a civil penal) of
not more than five hundred dollars(5500), y $I er0 0 Occupancy Type
0 1.as owner of tM pmpeny,or my employees with wages a their role compensation,
will do Be work,and the structure is not intended or offered for sale(See 7000,Business
f nd Pmrp nuonsim�.im a Contactors Liam Law does not apply to an owner of 506 — GAS TAP
Ire ns ec to
property who proves thereon,and who dons such work himselfonhrough his
own employees,provided Nat such improvements are nountended or offered for sale.N, 507 — FINAL PLU143ING
however,the building or improvement is sold within one year of completion.Ne owner-
huildcr will have the burden of proving Nat he did not build or improve for purpue of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
case law does not apply to an owner of property who builds a improve tMuon.and
who commcu for such projects with a enntracmr(s)licensed pursuant o the Contractor's
License Law.
0 l am exempt under Sec. ,B&P C for this reason
net
Date
WORKER'S COMPENSATION DECLARATION
I hereby alarm under penalty of perjury one of the following dalamtiona:
nd will maintain a CatificateofComsenno self insum for Worker'sCompen-
sininn.as provided for by Section 3700 of Ne Ia ver Code,for the performance of Ne
work for which this permit is issued.
. 0 1 have and will maintain Worker's Compensation Insurance,az required by Section
3710 of dm IaMrCWe,for she perfnrmence of Ne work for which this permit is issued.
My Workers Cn pcnsa nInaura cc cam and Policy numMrare'
Carrier: rPolicy NO.: �g3��
CERTIFICATE OF EJ EMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(This section recd not Ivecomplcted if the fermi,is for one hundred dollars(5101)
or less.)
I amfy that in the performance of the work for which Nis Permit is issued,1 shall not
employ any person in any manner our as w become subjecu0 the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICAM':If.after making this Celli Gcate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O Z forthwith utmpl y with such provisions or this permit shat l be deemed revoked,
Z O
P: CONSTRUCTION LENDING AGENCY
l hereby affirm Nat there is a construction lending agency lot the performance of
Gi the work fill which this permit is issued(S..MN7,Cu,C.)
lender's Name
Z Lender's Address
U Q 1 aftify Nat 1 have mod Nis application and sum that the above information is
tycorrectl agree to comply with all city and county ordinances and state laws relating to
O Vbuilding conformation.and hereby authorine mprcuntatives of this city to enter upon the
r W above-mentioned property for impcninn pmPOus.
(we)agree to save,indemnify and keep harmless de City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the graining of this permit. ^
^ APPLICANT UNDERSTANDS NO WILL COMPLY Wml ALL NON-POINT Issued by: Date i �— r=>3
� l
SO CE EGULATIONS. ///
���x[Si /� Re-roofs
Signature ofApphca on troy x Ithom 4iC2
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Fee applicant to future building cartoon store or handle hvardous material
az definN by the Cupertino Municipal Code.Chapter 9.12,and,he Health and Safety
otic.Secure 25S
❑VnnR(a)7 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant future building eaupant esu equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
7D,�l
hamNcus air comaminanu z fined by the Bay Arca Air Quality Management all new materials for inspection.
icIY❑Yes
1 have read the ha-mi01 materials requhcme0.amkr Chapter 6,95 oftheCalife'.
lcalth&SWelyCtd.Sccucr 255115.2533ud255}.lunderstandNalifthe holding • ,fir t rrently have a tenant.N t i,ix my rexports, ity to arm be rncupanl of the 1 ` � L.�ux,be m ar t. Ccnifcatc cl' ancyse . Slgnatu e o�Appbcant Date
er or authorized agrnl C (lJ raw
All roof coverings to be Class "B" or better