01050024 crry OF CUPERTINO
tory CONTRACTOR INFORMATION:
nmT,mrvc Drvts � T
BUILDING A DDRISS: ^ _ PERMIT NO. 2 .
PARBARA BAKER SOO AIRPORT BI=
OWNEWS NAME: r APPLICATIONS . A
/PIIONIi: `r49 `r747 SANITARY NO. CONTROL NO.
CCZ ARCI 111'1 iC'I'IENGINET:R: BUILDING PERMIT INPD
I�OOI- BLDG BI,fCI' PLUMB MECII
U{j 1=1 1-I I_1 I_1
N/a
zd�N i LICENSED CONTRACTOR'S DECLARATION O SCI
E Iherebyatnnn isvideatliamedand erpn,vi,hansofChapler9(,naneeing REPLACE 4C� b M'� WATER HEATER.
with Section 70ap of Division 3 of the lo,ines,vivid professions Calc,and my license
in full force avid effect.
O ¢ Liecow Claes I.ie.M
yyO Date Contractor
11i 3 u v ARCHI'I EM S DECLARA'I ION
F a 0 I undaatmd nay Plan,deep ha used m public reaardx FIRY�p�
A L E ID
a a Lieenwd Prolcssional
W o ON'Nr:R.BUII.DER DECLARATION JAN 0
by affnn that 1 am eaempl Irons he Contriver i Liceroc Law It,,the
1 here8 P002
F Z following icaxuu.(Semear 711.115,bueinea,and Profep,ions CW,Any city or,sonny
c F❑ which rc4rive,a pviont mnn
csfruo,alma improve,demolish,in,repair any nort one
a 3C=° prod I-:. Lo 4 -d i,n II hp ill 11 g dsacnn,
11,he is e,ajvvdp e , due p .oftn Contractor's[ Low(Chalner9 - Sy. Ft. Floor Ar UILDIN Valuat )
(cnmmeningwlh Section 701Dviaon 3 of the liu'nes adl I':. uCalr)
or that he i,acnapl thctd}nna and the bests far the alleged eaanplion.Any violation
of Section 7031.5 by any applicant(ova femit subjects the applicant to a civil penalty
of ndmore than fie hundred dollars(S500), APi�l u - Occupancy Type
❑I,av intact refine probedi or oly nnpluyce,with wages a.,ntdr,sole comper,edion.
Will do the work,and the structure is not intended or offered for side(Sec 7044, s ` — Y
B-inc,.0 and Prefes,ionv Code:The Contrition's License Law docs nor apply Io an Ir
w t of popery who bonds or in-pari,thereon.and who vlov.%ala work biusch 505 — GAS EST
nt though nix own employe,,pmvwed that such iinprovements are urn intended or
offered for vale IL homxver.Inc building or ldpnncment i%wld within one year of 507 — FINAL PLUMBING
nntpinion,the ownerbinder will have the burdec a1'proving thin he did not build or
Ingot,for purpow of sole.).
❑I,us owner el the ProPsI..int cacheivudy enncaeting with licensed contractors R,
construct the project(Sec 7144,Business and professions Cade:)The ContmaorY
License Law does not apply via est owner of property who heids or anpmvcs therein,
and cedes contracts Ibr such projmu with a tnnwetons)licensed pursuant to the
Contractor,License Law.
❑I an,eamnpl under See .11&1'C rev this reavon
Owner Date
WORKERS COMPENSATION DECLARATION
�hI hereby aflinn underlWnabyid perjnryonenl'the liddnwit,thelevelions.
0 1 have and will daimain a Cit"d cmc of Conwnt to self-insure for Worker', .
Cmnpeoverion, ;is pruvidnl for by Section 3700 of the Labor Calc, for the
perlimnma of the work for which this factual is issued.
❑1 have nod will maintain Worker',Contpensmion pnurance,as required bisection
3700 of the Labor Calc,for the performmrice of the work for which thin permit is
issued,My Witker's Compensation Insurance em pie and Policy n,mber are:
Cartier. Put'ey No.:
CER I IFICATION OF EXEMI'TI(IN FROM WORKERS'
COMPENSATION INSURANCE
(@is section nced not he completed If the pencil is for one hundred dollars.
151 W)m Ica.)
I certify that in the perfommnce of the work for which this pervtit is issued,I
,bull not employ;tit,person in any manner,n as Ice become subjwt m he Waded
C....Sri Laws of California.Date
Applicant
NOTICE'10 APPLICANh 11.:lien making suis Cenifealc of Eoervar o,you mead.
he,one,object b,the Wnaer'.,Compcnsmb.t prnvi m,of the"hot Code.you must
O Q forthwith comply with such previsions nr thl,fiction,hall he deetned revoked.
CONSTRUCTION LENDING AGENCY _
I hereby Blinn wet there is n eannlruation Icndin,agency to the Wrb nurna
of the Work for which Ibis a,r nil is!,,,.cd(See.3197.Civ.C.)
0.. [s, Lander',Name
= z 1<ndcr'.Address
C.> O 1 cent,dam 1 have read this applauume Land,viae drat the above mf nr nation is
4. F^. n neat.I agree m centplY with all city and cotan y ordinance,and ,are laws retain,
O V mhuildd,construction.and hereby authorve mpre.scntativcs of this enym enter upon
ry) Om ala vc.meainnm propcay rnr Inspcaion pugamcs.
F}" y (Wc)agreoit)save.indannifyund keep harmless.the City of Cupcnino against
.. r/a liabilities.judgments,costs and eapen.cs which uta,In uny way acenm a,uinsl said
U Z City in comequenae of the grading of this fiction.
^ APPLICANT UNDERSTANDS AND Wit.I.COMPLY W11 HALL NON POINT Issued by: Date
SOURCE RHOULAI4ONS.
Signalnre of Appfcanvcontracmt Dete Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future halving occupant More or handle hmuNous nmlanri Type of Roof
es defined by we Cupcnhal htunlcipul Calc,Chirpier 9.12,and the lbe tbh and Safety
Code,Section 25532(:07
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
�• Will lhcapplicanttithour,baiblngocea arduseegnipntemordeadcev Which If a roof is installed without first obtaining an inspection, 1 agree to remove
omit haaandou,via,curvaro)runs an deli tad by be de,Arca An Quality M:magemenl
Di4r1at7 all new materials for inspection. Applicant understands and will comply with
❑Yes ❑Na ail non-point source regulations.
1 have read the hvarri marerials requirement,under Chapter 0,95 of the
Caldron.Health&Saf ty Ctde.Section,25505.25533 vied 25534.d understand Ihm
if the bit Idle,dui,nut currently have a W,vvn.Inul h in mY regmmibllry to notifY'be
spam of the regniremems which nm4 be mcl prim to issuance of a Ceniticae of
Cicatrix, Signature of Applicant Date
Ownera aiduai"d agars Dale All roof coverings to be Class "B"or better
OFFICE