05010083 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT -coNTRACTOR INFORMATION:,-
BUILDING ADDRESS' PERMIT NO
05010083
li n�i c) ATNTCwnlArPU no _
OWNER'S NAME: PERMIT ISSUE DATE
RAYMOND nFSrAMP — - - SANITARY 7 13 '2�
ONE. - - - OL NO
ARCHITECT/ENGINEER.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Opp LICENSED CONTRACTOR'S DECLARATION IOb DDSCrIpI100 "-
x C 1 Mrcby um nut 1 am havcd under proves99nnsaf Clupror Y(ammencing
wM tion) )of DMnon]of NC BUanecaand Tetiona Code.and mYiiccna is
�„ mimeo derro � Lee,As � t X WATER HEATER REPLACEMENT
j,z License to
� conDECU AI.�rna-.� ()F3 t+� CONTRACTOR: DAN ALFORD PLBG
F j yder3fi RCHnECI'S DECLA AT
a� lu no my plans shall he used as puhlaa
JyU
3 u0 Licensed Pmfcsuonel
OWNER-BUILOER DECLARATION
,,<F 1 henchy affirm Ion 1 Am exempt fire the Conuactofs License Law for Cho
00 following season (Secuun 71131.5.Bvv
ins and Prefetsluns Core.Any City or county
K Q which requires a permit to construct.alter,improve,demolish,or repair any avumma
n print at US I....CC.also requnCS the applicant for such permit to file a Signed su9NmCnt
fro thathe.a hcensedNionn ou1.theprovi s;ovufthoCmumena"Lein-Low
(Chapter Sq.F[. Floor Area Valua[D 1800
¢� (Commencing with Section 7 0001 of Division 3 of the Business and Ptofcashons Code)or
i $
that he u exempt therefrom and the basis for the alleged exemption.Any vmlauaa of
Section 7031.5 by any Applicant for A permit sobjCCM NC applicant in a civil penalty of APN Number Occupancy Type
not mom than Eve hundred dollars($500)
32613114 . 00
❑I,asownrrk.and prophny,mmycmplayc.wiNwages rsalo(sole eampenavon. -
anldomcwmk.ands The Contractor's omraotinmcense Law China Apply to la,enamels - Required Inspections
and property who Code The te....License Law arcs not apply lf an owner is q P
property who butrovi improvesch moo.and who Aassuch work himselrorNmugM1 his
Own employees,ping oimprovement suchimprovementsareow not
year f cmphoon.for Aide IL
however.Ne budding or oving sold whin rim year of improve for the owe of
budder will have the btird[O of proving tat he tlitl not build onmprose for puryosc of '
Sale.).
/
1,as owner of ct propeny.am exclusively contracting Car liccnad ntinuo s'sa i-
cense La d project apply n in Business and properly who ov Cone.)The Comracro , rid j
cove Law arcs not apply je an owner of propcny who sedan or impvv.Ncreon,and
yyyyhiiiio contracts for such projccu with a convazmr(s)Laved pursuant m ire Convenor's
alit toes
crept undo Sec. .B&PCfor tins moon
Oner Date
WORKER'S COMPENSATION DECLARATION
I Mreby affirm under penalty of perjury one of ate following decimations:
*j,_I h an and will maintain a Ccrnfieate of Covent to self-insure for Worlds Compen-
sation,AS provided for by Section 37W of the Labor Code,for lie performance of the
work for which Nn p.it rs,.sued.
I ban and will maintain Worker's Compensation Ivurana,as rcgnmt by Section -
3700 of the labor Cade,for the performance of roe work for which thus permit is issued.
My Worker's Compensation Insurance Gamer and Policy number me.
Carom: Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs scchon need not oncompleted lithe permit is forone hundred dollars(SIM)
sir less.)
1 eevfy Nat in Ikp peformanceo of the work fm which thus permit is issued.I shall not
employ any pp�pran any manner so u m become Subject ate Workcss Compensation
Laws of CAI, Dr•^
Applhgm
'Y9QTIpE TO APPLICANT:If,altar making Char Cendieale of Exemption,you should
C$Object M the Workcb Compensation provhnons of NC IaMr Colic,you most
.J 7, forthwith comply with such prnvimov or this permit shall Ion roamed revoked.
Z O CONSTRUCTION LENDING AGENCY
P I hereby affirm COAL Here is a construction lending agency tot Ne perrormmen of
5 to,work fur which this permit u issued(Sec.3091,Civ.C.)
Lenders Nor��
r7 z lender's Add.e
U I candy that I have read this application rend lute that Nc eban information a
t" correct I Agra to comply with all city and county drdinar no and auto laws rolaung to
0U Wilding construction,and hereby authonee repreacmanno of N¢City to enter upon Nc
r W aimvomcntioncd property rot inspccuon purposes
F'6. (WC)agree to save,indemnify and keep harmless the City of Cupertino against
rp habdmes,judgments,costs and expcva which may in any way aCCMC against said City
U z in C[mSmU Cut of the granting Of this permit.
.. APPLI INT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
r GUR GULAT NS.
\1 rea Oa¢
ek � d� Re-roofs Q t /
'9�w
are of AppLCaHA�ARDO MATERIAIS DISCLOSURE Type of Roof l
Will the applicant or future Wilding=upon[mine or handle hvarrous material
AS deftncd by No Cupanmo Municipal Code,Chapter 9.12.and Cho Health and Safety
".dc.Sccuon 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Y .L N»
Will the aVpl,t.t or to,..buildingoccupant use iopmcm in thin.which If a roof is installed without first obtaining an inspection,I agree to remove
inn re haardous air conummann
As by the Bay Area Air Quality Management all new materials for inspection.
tard?
l—r ❑Yes ON,
1 have mat the haaanious materials requirements under ChaptertS 95 of Ne Cahfor
ma HeaLM1&Safety Cola,Selwas 25X15.255]]and 25534 L uridersund Nmrfthe hudNng
does not currently hash a¢pant that it is my removNilny in Way the occupant of the
req."ormouglibuch in nnCW5 mpnorini ssuance ofaceanhate ora_aparcy. Signature of Applicant Date
ea lR xal ,`�i 3 All roof coverings to be Class"B"or better
OwnauNOrircd agent 1 Dam
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
I A11
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPE(�TINO
Building Department
JOB ADDRESS: {{,, -,
t gu 1 S � IT # o cj O l
OWNER'S NAME !!! ,K a �eS C cirr.� Pt�oNE # S 7 33 4 1
GENERAL CONTRACTOR�f� FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
I ® SUBCONTRACTOR I BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
;i Plumbing :rl)�a� 4��ZI I? «,
Roofing I `I
Septic Tank
Sheet Metal
Sheet Rock
Tile
�} f- 1 -3 a �
er Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN # -3 2- 1o, 1 3 lA Date: ( 1 -3 Q j
Building Address: n
Ib 3 C 1 F s I.-�3 S
Owner's Name: �'� Phone#:
V-a� Co,lm-f
Contractor: _ Phone: License#:
A,
(-�>� fiordg3 1Q3�3
Contact: �Q. Phone: Cupertino Business License#:
rn
Building Permit Info:
Bldg - ❑ Elect ❑ Plumb 8- — _ -Mech_❑
Job Description:
Residential E3 — Commercial ❑
Cost of Project: 6
Strapped —9' On Platform.B' Bonded ,2�
New Location ❑ Replacement �—
App',- ble Fee ID Fee Description Fee Group
I BPWHEATER Water Heater/ Vent BUILDING
I -7-1 ) L(J I PPERMITFEE Plumbing Permit Issuance PLUMBING I
r BENERGY Energy BUILDING I
(� ) I BUSLIC Business License BUILDING
I I I