00100059 (2) ,CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IIU HAANG ADDRESS: PERh11'I NO.
OWNERSNA.M7.995 RRINBUWAPPIACADON. 1 I A '.
']ONE: KENNETH En3 SANITARY No. 0 I. .
C ac ZZ- ARCH]117CII17NGI NITER - 1- �- — RUILDING PERMIT INFO '
rsY W_ 91.DC, IJ.IiC'I' NUMB MUCH
�NZ LICENSICDCONTRAC'IOR'S DECLARATION , Job Description
ZO-I•'= L henLy affirm mal 1 am licensee ander pnhvisinne of CM1nprcr v(mmnancing
G with Section 70011 of Uivi.ion J of the Business and I'roles,Ions Code,and my license
is in full force and effect.
z6 iana Cla" Li,.M
'o a Date Cmnractor REPLACE WATER HEATER
4 ARCHI'I'EC`fs DECLARATION
1 mndentan l my.lam shall be used use public becnrds
to
,cu E p z Userwd I'nde,slonul
ee a. OWNER-BUILDER DECLARATION
LLI hereby affirm that 1 a exempt from the Contractor's Licenm Law for the
I- >' following reason.(Scellon)0316 limia and Professions Code:Any city lir county
Dwhich e,aira.a El.nle w cau"I....alto..::...love,Amnulinh,lir rc,;ii,any n,m,abc
prior in issuance.also n .am,the app wow for wch permit ah f ill,a signed slolerrom
a's° m that he is licensed parcamlothe provisiom,dtheComcau,rsLiceraw Law(Chapter 9 Sq. Ft. Floor Area
Valuation
(commencing with Section 7000)of Division 3 of the Husiness and Professions Code)
lir aha It,is e,Oup,Ihcrcfro a::n I thc baxie Wr mc alleged exemption.Any violator
of"Seat on 7111.5 by ally upplic:ml fill a Ionni,subjects Om nPdicaul m v civil penally
of not more anflvehundreddnnar.($5au. APN Number
moccuparICTIM
❑I,as loner of the property,or my employees with wages as their sale com,sbaalin. -
w111 do the soli,and de a ut,lure is sol i twal or offered fur nine(Sec.7(44. 36v
lfc,ir s and Pmfc.sinm Cole:The Contractor.License Law does ran apply a.an "'-�" R&-ed Inspections
mwbe,of pmpeny Who build,lir ion,al thercon,and whit does such work himself
through his own enhployecs,provided drat such improvements are not intended lir
nomad It,.:ni, Ifhowever,the holmn.lirimprove..tentie,oldwithin...leyearof 502 — FINAL PLUMBING ENERGY
imnpletion,Ile owner-hullJcr will have the Imrden of proving the he did all huild o,
mprove Bnpmmnse orame.). 506 — GAS TEST
❑1,as owner me propel,a !n.elusively corralling with licensed cnmr,mnr m 507 — FINAL PLUMBING
,n,rI, leepn6,,,.70,14. axme,,;,,it
Prh&..Iom Code q) the CooVictor
's
I1nd who
Law dors nal apply m.,I owner M acont who halide seimproves thercon.
and who Law
does for such projects with a contraclno b licensed pursuant to that
Contractor's Liccme Law.
❑I am even p,mods,Sr,. .11 k 1'C for(his len...
Owner Dae
WORKFCOMPBNSAaryowDECLARATION 1
I heresy ulnu'9undcr dtt Penally of pvIjnrone nl the liillnwing declaration,: !/ -
I I have and will mai main a Ceni ream of Consent to .el6imm a for Porker's v (1
mpmrenioo, as provided for by Section 3700 of the Labor Code, for the lJ
perfonnumc of the walk for which his pcnnil is ie,wd,
❑1 have and will maintain Workers Compensation Insurance,as required by Section
J700 of the Labor Code,fir the performance of the work fur which this pcnnil is
11
sued.My Wnrktt'a Cm.ipauntiao Inse'luee camel nn I Policy mother am',
Carrier: Policy No.:
CER I'119CA'noN OF MzNI TION FROM WORKERS'
COMMENSAI iON INSURANCE
("is section need not be completed if the pecans is for line handbill dollar,
(SIM)or Imv.)
1 e,rlil,Ilial in the perl'nnumec ul the work fnr which this permit is iowd.I
shall not nnploy any person in any wormer so as to become.object to the Waken'
Conservatism Ww>or California.Dam
Applicant
NOTICE'ID AITI.ICANT.If Ulla mekillg Ihlx CenlFente of Eaemptor. ,in send
below subjcn to Inc Worker:s Comlxosution provisions of the Lobor Colic,you must
O O forthwith comply with such provisions or this pcnnil.hull be Jeemcd reboked.
v) CONS1 RUCTION LENDING AGENCY
1 hereby alRno that mere Na cnmlruction lending agency for the larRmnance
five vnd far which his pebbu is i...ed(Sec.3097.Civ.C.)
(, Lender's Name
PJ. 7 Lcndcr'e AJdmss
U O 1 cenify,ha,I have read this application and state that the uNice ironnoion Is
ks [ter correct.1 agree to aonhply with all city and county onsfir tae and state laws relating
O U m building constraalon.and herchy anchorite representatives of this city to enter cryo
iy die nbnvo-menlnned property Ihr'ImpcoimI Purposes.
[r L Pad agreem save.indemnify and keep harmless the City of Cupenlno agaimr
V1 If ibilitia,judgmentm evil and espmaws which may in any way acme against said .
U Z City in colmequence lir the granting of this pernnt. / /(O
�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �
SOURCE REGULATIONS, y'
Signature of ApplicaMCommoor Uac Re-roofs ,
I IAZARDOUS MA I'ERLM.S DI SCLOSIJR17
Will Ila appucan or Into,holding occupanumm ornaudla ha,.unln...x m:acdw Type of Roof
as def ned by the Cupertino Milovipal Code.Chapter 9.12,and the Health and Sofa,
Code.Stoma 25532(x)7
O Y n ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will Omapplieaa lir future balongrecupam live rum,brof m devlec,which 11'a roof is installed without first obtaining an inspection, 1 agree to remove
e'm`crh'urdous air nrmaminan,sa,dcfstat by the gay Arca Am Qualiry Management all new materials for inspection. Applicant understands and will comply with
OYee 0 No all non-point source regulations.
1 1 have read the haiurdnux mararia9 tequircmcm.s under Chaplo 6.95 of thc '
California Health&Safety Cole.Sections 25505,25533 ad 25534.1 understand that
if the building dosis lint currently have n Imam,that II is my re,omibility to notify the
masa of Iha bo,too:ncnn which Inmel ba mal prior nI:masae of a CeniOemc o1
occupancy' Signature of Applicant Date
Owre,r, mmnuld!agcnl Date All roof coverings to be Class`B"or better
OFFICE