03010173 (2) CI'T'Y OF CUPERTINO
BUILDING DIVISIONp1:RMiT CONTRACTOR INFORMATION:
BUILDING ADDRESS HOT WATER INC PERMIT NO.
20345 VIA VOLANTE 03010173
OWNER'S NAME: 2531 GRACELAND AVE APPLICATION SUB DATE
ELIZABETH REILY 01/28/2003
lipIONS: (650) 298-8494 SANITARY NO. CONTROI,NO,
ARCHmiLT/ENGINHER: BUILDING PERMIT INFO
BLDG BLECT PLUMB MECH
LICENSED CONTRACTOR'S under
nO r provisions of hap
� ON
�p IherebyafprnInasIamReece,anderndPoioasorChaptervmylicenseis Job Description
U wig Section] qaf Divi ionJof the usi and Profrssiov Code,andmylicense is p G
�o inrallrrt�err,. 3(0 3(a Z REPLACE WATER HEATER �'��L�'®
zogz License a.
F=F� Dam
Cie.
V
�Q/ ARCHU., S I.ARATION / �J
�o Uv Iundersundmyplarviroul Musedas Micarc^rds JUN 1% 8 2007
u�30 Licensed Professional
N
OWNERBUILDER DECLARATION
1 hereby affirm that I am exempt from the Contramors Lima.Law for the BUILDING
i S p O following aawn.(Section 7031.5.Business and Pnifeuimer Cad:Any city or county
$ which requires a permit to construct.alter,improve.demolish,or amour any structure
r prior to its issuance,also acquires the applicant for such permit to r,le a signed smemem �p,,rT l�
e=< that he is licensed prmant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area $YAuauatlon
G (commencing with Sectiort7000)of Division 3 of the Bted.eumnd professions Code)or
$ taut he u exemptm Urn froand Bre bssis fm Ire alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects ftapplicant to a civil Penalty of a Occupancy Type
not moa than five hundred dollar.(SSW).
502 I,acv awnerofthe progeny.or my employees with wagesu dmir.ole compensation,
will do the work,and Ne atrucma is nor intended or oRered forssle(Sec.7M4,Business
ROY
and Pofesslorts Cade:The Commotors Liartste Lew dors not apply to an owner of 506 - GAS TE elqutre nspecuons
property who Wilds or improves therem,and who doessuch work himselfor through his
own employees,provided thatsuch improvements am not intended ormffncal hsrsale.If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of complefion,the owner-
Wilder will have the Inrde s of proving Nat Ise did not Wild of improve for pugmro of
sad.).
❑I, a revue,of the property,am c.clusively contracting with licensed con mettars to
convect the project(Sec.70,4.Business and Professions C"I The Contractors Li- .
cteme Law does not apply to an owner of propeny who Wilds or improves thereon,and.
who contracts for such projects with a mousetraps)Iiarlsed puraoam in the Comnetors
LKCM1tc La W.
❑l am exempt under Sm. .B&P C for this rcaznn
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm matter penalty of Perjury one of the following declarations:
I have and will maintain a Cenilicate of Consent to self insum for Worker's ComPem
satum,as provided far by Section 37M of the labor Code,for the performance of the
work for which this permil is issued.
❑1 have and will maintain Worker's Cmmpsoundon Insurance,as required by Section
370K)of the Labor Cade,for the Performance of the work for which this permil is issued.
My C. 4,
Com cnxa)mn In rencc caryc Policy sNocY numM e�c _ _
CERTIFICATE Op MEEIMPPf10N IR ORKERS' 2Sfr�
COMPENSATION INSURANCE
(this section need not rte completed if the permil is tarmac hundred dollars IS app
ar less.)
I certify that in the Performance of the work for which this Permit is issued,I shall not
employ any Person in any manner in az m Become subject n the Workeu'Compensaunn
Laws of Califomia.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccrtiftcate of Excmpuon.you OWN
become subject to the Worker'Compensation provisions at the labor Code,you must
QO forthwith comply with such provisions or this perm it shat l M deemed revoked.
'Z fA CONSTRUCTION LENDING AGENCY
(-. 1 Bereby affirm Nn Bare is a momentous lending agency for dte perfurmana or
fk 7 Use work fur which this permit is issued(See 30fel.Civ.C.)
fat n Lenders Name
z Lender's ABdoss
U O m certify Btu I have read this appliaunn and sham that the move information is
lS. f" correct.I agree to comply with all city and county ordinances and state laws relating to
�U Wilding convection,and Bereby mutatia reprime advesof this city to enter uqm lW
lTa ahove-ammionod property for inspection purposes.
(We)agree In save,indemnify and kap harmless the City of Cupertino against /
h liabilities.judgment,costs and eapenaa which may in any way accrue against said City
U z in consequence of the granting of this permit.
APPLCANT UNDERSTANpS AND WILL COMPLY WITH ALL NOON-POINT Issued by: Date
U -GrmIGN - 1 I2�/�� Re-roofs
nawnic of liplicaMConoacmr I I " Date
I IAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building acupant store or handle timorous material
az Jcfined ny the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
rdc,cd n 211%(P.)7 _ / All roofs shall be inspected prior to any roofing material bein 'nstalled.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air commeal arta as defined by the Bay Area Air Quality Management all new materials for inspection.
7Districi?
❑Yes No5.V)5, d255ihundirullh&Snfcly Gdc,Scctinre25A13.25571anJ25514.1un dnanJthatifthe Willing
I cure ray hose a moan(,thm itis my rarytmihility redly tW recupam of the
hmaxt nompriormtitsamnecmnceBream g F�cr Signature of Applicant Date
kAo-i �I�Zglo�
Owner nr anda rued agent — I All roof coverings to be Class "B"or better