01020102 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10885 SWEET OAK ST WATER HEATERS ONLY 01020102
OWNER'S NAME. APPLICATION SUIT DATE
POLSON MARY A TRUSTEE 500 AIRPORT BLV 02/20/2001
PHONE: SANITARY NO. CONTROL NO.
(415) 349-3747
�Q 75 ARC)IITECDENGINIIER; BUILDING PERM ITINFO
u— BLDG ELECT PLUMB MECH
Nz 1=1 CI t=1 CI
Job Description
.z. LIGIshtIDCON'nsed order SD1iito,ofr10N
z_ I hemby aRrm that I um licensed order pnmisinnx of CM1aprar 9lcommencing
,n Ftu with full fon Y(XX))of Div an al of the llu,ineo:nN)'role<,imme C,de,ani my lir
<y °ur°"` "Je REPLACE 40 GALLON WATER HEATER
ace 6< License Class a l.ia.a
aUulc Contraen,r
S a,n ARCHITECI'S DECLARATION
t 0 3 1 undenlund Iny plau,'hull be need:..p,thlie,.caul.,
to
i�p Licensed ProfeWond
arIit,
onthe
�1 hereby aflimm that 1 un,cxcmpt OWNER-BUILDER DECLARATION the CRiiccmc law hn the
t:Ke�, nflowing m,.,n seen 17031.5.limine,,,and Profe,6no Coale:AnY city o,canny
M D which requires a pemdt to commuct,alter,improve,demolish.of repair any slocone
u°33m
prior o hs lxwancc.oho rcyuims the ap,licatn for,uch pencil ,,Raasned,tncmcm
that behhcenaedmiro n) m
ldavmc Law(ChaplmlSy. Ft. Floor Area Valuation
(rommenciny with Sntlott 7m)0)of Doirinn J nr,bo 11u,inwa rend 11 to sinm ender
or that he is exempt merefmm and the nask for the alleged exemption.Any.;olmom $700
of Sectio 7031.5 by any apllcant Pura pcnnil ,tbjccw tit.'Pli'm m,a civil penalty
of ren mom man Ree In had dollars(g5len. APN Number Occupancy Type
01,as owner of the property,or my employee,with wages as two sole enaTenmtic.,
will Jo the.,it.and the.mature is not imendal to otk d It,,tale sev,.7(W.
Polito"ail P10111 all Code:'nae Omtmat.r's U,ansa Law area not apply t„an Required Inspections
owner of propeny Who hail],or impmmr,thereon,and who docs such work himxlr
or formals In,own employee.,podded that such nnprmcmants ore not bounded m 502 — FINAL PLUMBING ENERGY
nffcmJ for xWe.If,bnweva,the building art improvemcm i,sola within some year of
„nnpletion.the -ac,b.ild,,will live the buten of proving that he did not build or 506 — GAS TEST
mmve Rol pa,pnee nr,llle.). 507 — FINAL PLUMBING
❑I,alt owner al Ilia propen,ton...lu,iwly cantfaeting Willi hren.ed v n uabas to
instruct the project(Sec.7(94.Business and i tuffs. lo„s Cod.:)The Contract.,',
Liculcit,Law does our apply I, of pnq,coy who build,n,in oo Ile thereon,
and who conloors for,such pmjess with a cou aatm(d licereed paramour In the
Comoomr's License law.
01 um Ls rept under See ,It&P C for this reason
Owner - hate
WORKER'S COMPENSAI ION DECLARATION
I hereby affcar under penaltyof perjuryone of rhe following fluctuation,:
�. ❑ 1 have anti will maintain a Cenificam of Concept to self-insure for Worker's - -
Con,cmation, as provided for by Seetion 3700 of the Labor Cade. for the
part ane,of the wad rnr which this,permit is snored.
01 base and will ntufnuin W..kn'x CmoTen,:nio i Bnarance as required by Section
3700 of the Labor Code,for the performance of the work liar which this permit i,
Issued.My Worker's Ciampenmtion houraue,aarria and Pul'ev mmnaber arc:
Carrier: Policy No,
CITIC IFICATION 01;E%EMPTON FROM WORKERS'
COMPENSATION INSURANCE
(Thi.,section need not IN completN if the permit is for one hundred dolma
ISI W)in luso.)
1 eerily that In the perfonfance of the won,for which this permit is issued.I
shall not anploy any person in any manner on as m,Ias,me subject to the Workers
Conn'to.inn law,of catho rcia.Date
A, heart
NOTICE 7U APPLICANT:If,aper making mi,Certificate of Eaemaion.you should
_Ment
ne subject to tha Wnrker'o Cutup...am au prov.,iovs of the LnMn Cade,you mull
Q O forthwith enmply with such Pro vision,or this pemmir shall be Deemed revoked.
z
^F ^
CONS Ihe RHCiION LENDING clileAGENCY
�. I hereby which thus then i,s mnxtn(mbn(N7,18 agency our Ina iurfonnona
ut the work for which thi,Purmit is issued(Set.31x)7,Ci,C,)
Pa Q Isndar'e Name,
7 Z hcnJer's AJdres,
U Q 1 cunlly that I have Iced Ihi,applicutin"and state that the above mhmnadnn i,
W P cameo.I agree n,comply with all city and county on inanees and state laws refining
Q U to buildings nammiun.at hereby uutmn,a,a,oc aaIa.....of t hiw'my ,,enlar upon
>, r� the-ahove.lnemioned propeny for inspection purposes.
a
(We)agreem,avc.itdemldy:mJ keep cmmlexs the Cayof Cupertino aF,inq
r 7) Ii:Ibiloo,juJgmcnt,,ensu:mal expense,whwh maty in any way areae against said
U z City in a.n.,c,.ervc of the grammg nr,bis permit.
'—I
APPLICAN F UNOERSTANDS AND WILL COMPLY WITH ALI.NON-POINT Issued by: Date
SOURCE REGULATIONS, Y
sgnamre nrnpphcamrc„ntnhctm Date Re-roofs
HALARIIfIUS MATERIALS DISCLOSURE
Wil tbcaspic; IWon,boliin,mcupert,mreor handle na,aaku,maadal Type of Roof
as defined by the Cupertino Municipal Code,Chapmr 9.12,and the I Iczhh aid Safety
Code.Section 25512(")'!
❑Ye, EI No All roofs shall be inspected prior to any roofing material being installed.
Hill the alfaicam or future building occopam use equipment or devices which If a roof is installed without first obtaining an inspection. I agree to remove
•soh harardou,air coammilunu a,Jefined by the Bay Area Air Quality Management
co
all new materials for inspection. Applicant understands and will comply with
• 0yes 0 N all non-point source regulations.
1 have read the mmidou,materials n mmmams under Chapter bni of the
CNllornia Ilton,tit Sdcy Coac•Semon,255115,25533 and 25534.I undealund that
tribe building does not currently have a tenant,than it is my m.ry,nsfili y m nobly the
wm culwof the requiretncros which oust he tucl prior ,,inxuuncc of a Ccnifiamc of
Oc''Iptmey. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class "B”or better
OFFICE