01070107 CITY OF CUPERTINO ' "^*^3 '> +ea
BUILDING DIVISION PERT "co RH4T R L1\1,c0 TSON
BUILDING ADDRESS: PERMIT NO.
WATER HEATERS ONLY 01070107
ling 211THERIP.ND All
OWNER'S NAME: PERMIT LSUE DATE _ _
ONE:
r SANITARY OL NO.
ARCHi7 cTfENGINEER: BUILDING PERMIT
BLDG ELECT PLUMB
MECH
C=
_a0 LICENSED CONTRACTOR'S DECLARATION — - lob Descrlp �� ^--- --
1 bereby affirm that 1 am licensed under provisions of Chapter 9(commencing
i with Section 7")of Division 3af NC Business and Professions Code.and my license is
in full force and effect.
j viz License Class tie. REPLACE WATER HEATER. D
zFo Date Contractor (40G GAS WATER HEATER. )
££� ARCHITECTS DECLARATION --
C 1 understand my pinss,hall W used as public records
JyU
0 Licenmd Professional
OWNERBUIIDER DECLARATION
1 hereby affirm Net 1 am exempt from the Contractors License Law for do
E00 following reason.(Section 71171.5.Business and Proeanium Code:Any city or county
K 2 which mquims a Permit to cmuses,altar,imprnw,demolish,of repair any suuctare
°sly innormi%issuance.also requires the applicant for such Permittorileasignedsa¢mem VaIUaCI
< shat he is licenud punuan0o the provisions of the Contr¢mr's License Law(Chapter 9 Sq.Ft. Floor Area Qi1700
y�$ (commencing with Section 7")of Division 3 of the Business and Professions C.&)or `7
y that he is attempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a Permit subjects the applicant he a civil penally of APN Number Occupancy Type
not mom Nan fire hundred dollars(1500). '
01.aowres orthe lnopmy.mmr cmploym with wage atKir axle camiscnsadan; 35617061 . 00 _
willdo thewodt and thesuuctumisnotiretandedoraTTared for We(Sec.]044,Bud. Required Inspections - -
and Prefossions Cade:The Conhaloh License law does mol apply m an owner of q P
progeny who builds ororphans thereon,andwhodues suchwork himselfor through his
own employes.provided thmsuch improvements are not intended oroRared for We.If. -
however,the building or improvement is sold within one year of completion,the Framr-
builder will base ON burden of proving that he did not Wild or improv for purpose of
ale.).
0 1.as owner of the property.am exclusively contracting with licensed communist to
construct the project(Sec.7044,Business and Professions Cade:)TW Conmetors U-
cense law dors oat apply in in owner of propony who builds at improves thereon.and -
who contracts for such prejectswithacon.w,(,)licensed pmemrtt to the Conhacmrs
License Law.
❑1 am eaempr under See. .B&P C for this reason ���,�<D
O
'N' Dam rat
WORKERS COMPENSATION DECLARATION ,
I hereby affirm under penalty of perjury,one of the following declarations: - -
1 have and will maintain aCentfrcom of Consent ro self-imure for Warkterl Camper
as,as provided for by Section 3700 of the Labor Code,for the performance of the -
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Ituurana,a required by Section
0 ofthte lane,Code.for rhe performance of the work for which this permit is issued.
Worker's Compensation Insunna artier and Policy number art:
rtier. Policy NO.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars(SIM)
in,less.)
1 unify thus in the performance,of ther work for which Nis permit Is issued.1 shall nos
employ any person in any mannerso as to Wcome subject to ON Workcn Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifrca,Of Exemption,you should
become subject to the Workers COmpetualion provisions of the labor Code,you must
,J O toMwitb comply with such provisions ser this permit shall W deemed revoked.
z N CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that them Is a construction lending agency for the performance of
the work for which Nis permit Is issued(Sec.3097.Civ.C.)
fy A Lendcea Name,
6a Lenders Address
V 0 1 ccnify that I lugs read this application and sum that the above Flemutiun is
W f—' connect.l agree to comply with dl city and county aNinanNes and sou taws relating as
r upon
V building
(We)agresi to
authand keep
Wool.
City of to menu ago the
r W anovomentioad property for impaction purposes
(we,)agree to arc,indemnify and keep harmless the City of Cupertino against
F'N liabilities.judgments.cmts and teapcnees which may In any way accrue against said City L6
U Z in consequence of the granting of this Permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of A,plicsmVCOmhNx,,
HAZARDOUS MATERIALS DISCLOSURE ata Type of Roof
Will Ne,applicant or futon Wilding Occupant store in handle harudous material
n defined by IN Cupertino Municipal Code.CTaper 9.11.and the Health and Safety
Code,section 15531tayf - All roofs shall be inspected prior to any roofing material being installed.
OYm ON.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant of future Wilding occupant use co Air u or M... which
mit havardnus air contaminants u dcrincd by the Bay Arca Air Quality Managcmcm all new materials for inspection.
ishiet7
❑Yes ON.
I have rorJ the huwdnus materials requirements under Chaplet 6.95 of the Celifor
u Health Saletyfodc,&coons 25505.25533 and 25534.1 umlcrsund that if the Wilding
does not cmrendy haw a count.that it is my responsibility m notify the occupant of the —
requircmentswhimmuil W met prior w iaumee Of a Ccrdricae Of occupancy. Signature of Applicant Date
IF
e
Date All roof coverings to be Class"B" or better
Owner or authorivcd agent