01080124 'CITY OF CUPERTINO': ' " •••: r• . n: :
."BUILDING, DIVISION. ': ,;,,pER1VII'T_;"' 1 CONTRACTOR INFORMATION•.
ba�L.'(:U•' Ili •i'-11tC1I-1l PERMIT NO!.L ! -
;: 0T0832:_N0RTH'FIEL
IF •_ •„ D, .SQ",' ; •Ir,;, WATER HEATERSt.ONLY,;;- ;(, l,, ; ;;01080,1-2,41., '
dam ' OWNER'S NAME"-' '" ,.....-,«y`__,:.. ...rv�.. .._•_....__...__ ,...._.__�_..__......�.__.. _
APPLICTi
.-. '- _ -_____,.____-...__-.-__- 90N5 B'DATE'-'•.
SCHULTZ.'AVIVA 970''OE�EMAIN ST, SUITE 20D08)27'7
Ali
PHONE: SANITARY NO. CONTROL NO.
(415) 566-2209
O'rt'z ARCHITECT/ENGINEE0.: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
a Z:. r-1 LZ71 1__I LI
fan
LICENSED CONTRACTOR'S DECLARATION
N 1 nemby affirm that 1 it, wormed ander imockiom orCh.p,n91 orenang ' . - � ...Job Description -
!wt-v-• with Section7(M)ofDivision3undamBnsin<ssunJProfession.CWc,anamylicense REPLACE 40G GAS WATER HEATER
in full forte and ribec,+
i as z< License Class Lie.e
1 O a O Dane - Commcmr
LL C G ARCHITECT'S DECLARATION
g 1 unJeasmnd my plans shall be used as Public,ec ml,.'
I X c O Licensed Professional
K o OWNER-BUILDER DECLARATION "
1
i haaffirm that 1 oro u<mm r' ,h Contractor s Limnos laaw for the
CZ following reason 7031.5.Bus d,P, rc: Code Any cry county
E whrth rtgmrca permit 1m cnmruct alien mpm<,JcnolisM1,or repairranylwnum s '..' ' $700
1
'
d Is .praor sewn,akw reg P< gard -
'Pathd sl dpunuubnothep vision..!the Contractors L Law(Chapter oil.) s C ati , - Valuation.
' �`w.tea,,{:J��a p,� t ..�.,r.
Icmmn is
with th om an (Di basis drof the be
tlion.sy nsCWe7a.3 Y0'J•T •_7 .-lTe I•x is ,
or that io 7 31:5 b any Wti and the basis for,be alleged palma to Mrd Pennon
of Seniors than
LS eshyapplicantfar0pemut subjms'theapplicom'oocivilpenotry- N{....a:Ix
'.rnmmmrcmanfiveWnertaamJars(a5) 1. " - t"'1502``P1*4;4u 'IV'AL PLUMBIN ENERGYO'ccupancy_Type
%. •O Las more,vf Nc proFcny:"o:my emplorici with wasu as their sole mropenaalim, '' '!n'.'., b, I C' f;iD". .•:)" tt 3:I Cf
'will�do the k aI,sh km,m..is rm , ded:m:oRerce.for sdd(S<c.A04y: _..__.-......._
Business and Pmf ii n:Code'Th Com to 'Lima.,Law doer not apply to an .5 0.7.
. — ..FINAL-`.Pl�t d}91H'�d+A'3specttons .,
owner of property Who builds or improves Itho mn,and who doer such work Nmsof -•' -•
or through his own employees,provided that such improvements am not intended or -
" ' " (fend for sole.If.however,,he hoildin' t iv sold within are f -- — - --- — --_- "— - " -'- -"-
.. g.rimpmvemen Y<mo ins' :r Ira 1
oeioo,the owner-Wilder will have,he Wrden of proving that he did not build or
improve for purpose of sale.). '
conmmwhaiofmctp(Smny,ume Business and
Prfessins licensed comracmrsro NI :. ,
.cans,the does
n INa.71Han Business aid Professions ills or The Convenor's q, •;
Liana Law docs not apply man owner of property who builds or improved thereon, l
^ - .-end Commucomets for such protects with a convacmr(s)licensed d pursthe
su '
01..raLicense law.
❑lam nmmpt under Scc. '_ 1 .B'&PCfnnnte
his reason - - t•" '+' ^• s"u -
Owmsrr ' PIDIALED
WORKER'S COMPENSATION DECLARATION
hereby affim:undo,pcpahy of perjury,a. ofthe fmllnwing dedmaions:
01 have and will maiulriin o'Cenificale of consent to self m,nm for Workers OCT 1 ,1, 2001,.
Compensation, as provided tet by section 3700 of the labor Cate. for the
parr mora f[he work for which this pum t is' ed . . I''
❑Ihave nil willmirrumWmker Cmmpc t brsmrv,rsrequired bySection - BUILDING• -
Tltp of the Labor CL9e for the perform nce of the wmrk.rnr which this permit is -'1 ii 101, - �'•1 ' :
brand My W k s Compensation Insurance carr¢,end Policy number rc ,
v..
"! Cara I v Fahey N..: nn.v , L •. ., , ;xs i�T.kt "i"11 r 7 S. s ... 1
1' CERTIrICAT10NOFEKEMPTIONFROM.WORK-R$R" I I e \••
COMPENSATION INSURANCE` _-. ..r-.�. -
` (ni,veceoo,ecJ'naWromplatea !the Penni,isfor ox hundred dollars 'I il;\ "It., � r .,Ilrr ?`" a
-- 131001 lets.) ,on
shill not in to m ,I' . •-'-_ ,•
;^ ,1<nvygnat i,irc nfronYrmrm sar "comen. pc rissued:1
In an mann a jo trco,rc 63 t m the Workers n - 1!, •. I'.
Compensminalawsmf California" Date, '
APPlicam ,. .,. ._.. _ _
NOTICETO APPLICANT.11.afrcr makin,'his Certificate of Exemption.,"..should
become wbjccllo the Woikea Compensation pmbisiohi of the Labor Cale,You must
s
Q 0 .-
forthwith comply with such provisions or this Permit shall he eeemed revoked.
Zr -.. ..,-. _ --. _ .- , _ . - .. __. __.. ... . . . _. _ - - -.
F'I14 `` •'."nr 'CONS IUCfION LENDING'AGENCY I' ' .. " l,'.';,.-- ,t I... ...
1 h mby affirm that there, Drat t I M g agency for Ne perfmmg e
ofthe workfn bich this pi i, issued IS"31197 C..C.)
o Z Lendcr's Address ... .
V C
-t•"',Fy• 1 minify that 1 Phaad'hpplic application
mm that thWf 'maon,s
correct.18et comply h 11 and ,sordinances 'd state laws ng
O' ) mWId sec do tln byeuntio a pica ruts lwenter
upon T
�w(] the bid m •d pen,forpoi he V
a
,1P l g re 1.save:,dem f)and kep numlm city _vr{-V✓l/y)t.J^`
-�
of C pen o against
y liabilities,judgmcme,costs and expenua which may in any way accrue nga;na said ,
C).Z City in conscyuence or the grnn'ingof this permit. , ' ' -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALCNON-POINT Issued by: D3I0 '
- SOURCE REGULATIONS../ ' y'
sig tarerApplican,/Cmanect6, . Date;..,' Re-roofs;
.• HAZARDOUS MATERIALS DISCLOSURE `
i,,'. will Jac appl wed mrc W
f 'Id'g occu «
py' ort handle IbLa d.0 tool Type of Roof
as defined byhc Cupert n Municipal Codin.Chapter 9,12w and the Health and Safety2;_'-}) -,•
Code;Scni.n 25532(01'' ' r ; Ila Y,a,-1 y� ",r f: ' , r - '
EI Y<a ••^• 1' oNm,'''• her• + + R - Ap,roofsshallbe inspectediprior to any,roofing,material being installed.
-\
Will the nprc to chullJinb pant me"cgripm n. d man. If,a roofis'insfalled'without first obtaining an inspection;I agree'.to remove
mm
emit lut.rdous air coai amimdefined by the Bay Area Air Quality Managcmem
'Diaz ' - all new materials_for_inso ection.'Applicant understands and will comply with
e .oY x oNm. ., , , ,:. ,-` all^hFn-point sourcereglations: - - -- - '
- - have-mill ,t
1 the luJmdous materiel rtgmmr,mnli undo Chap,cr ti.95 mf the
Calimmia Hcdth&Sufcty C6Je.Sections 25505:25533 and 25534.,1 understand shat
if the building docs no'cumcmly have a mnamahm n is my responsibility,to only he
'acupam cf the to issuance of a Cenifieme of
C1. is Oce.,1Cr' , reqs: ,a. Pro 4 . Signature of Applicant Date
requirements which must be met r
C ..... ... -. .
"' " ownerter wmw;:ra ag<n3•' -' ,rr;.- "Dan, All roof coverings to be Class •'B"or better"
z:•: - . . ,OFFICE