03100075 CITY Or CUPERTINO IS mix= ..Fe.�
Buu.Dllvc DrvlsloN PER * CONTRACTORJNPbRMATION ,
BUILDING ADDR ESS: HOT WATER INC PERMITNO03 10 00 75
OWNER'S NAME: 2531 GRACELAND AVE PERMITLSSUEDATE
SRIHARI KONDA 2003
NE: (650) 298-8494 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I lot,
Zp LICENSED CONTRACTOR'S DECLARATION
w I hereby affrm that I am licensed under provisions of Chapter 9(commencing Job Description
Z. � with Section 70M)of Division 3 of Ne Busineas and Professions Code.and my license is
jamin Tall fnrec and LZ. WATER HEATER REPLACEMENT
Licence Cl � I Lic.M_
et Dam Contraclm
epp ARCHITECTSDECLARA. N
G W 1 understand my plans shall he used as public records
a� Licensed Professional -
Oat lam exILDERempt
DECLARATION y
<� 1 moan affirm un 11. exempt from the(exons Co e:Any c Low for the
3pO
whichBillow
guiresa Scniun]tA1.A Business and Profeasinmh.or Any city county /�� 0
$� which requires a permit to construct,elmr,impmw,demnliah,or repair any rtmeture - / s+ ' l
prior o its issuance.also requires the applicant fnsuch permitm file a signedammmcm
epc that he is licensed pursuanttothe previsionsofthe Contractor's Lim=Law(Chapter 9 Sq.Ft. Floor Area V `- ..Val'oatio`n
(commencing with Section 7")of Division 3 of the Business and Professions Code)or /�\� /
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 32630008 . 00
} j
Section 7031.5 by anyapplicam for a permit subjects the applicant to a civil penalty of APN Number C4 ane e y
not mom than five hundred dollars($500). --
❑ 1..owner or the property,or my employe.with walla.man sole crampcnmtion,
will do the work,and the structure isnot intended or offered fandc(Sec.7044,Business bU2 —
and Profession Code:The Conuacmr's License Taw does not apply a an"Our of eC j
propeny who builds or improves thereon,and who was such work himselfor through his 506 - GAS TE J
own employcet,provided Nal such improvements are not intended or Offered for sale.11. 507 — FINAL PLUMBING
however,the building or improvement Is sold within one year of completion,the owner
builder will have Iha burden of proving that he did not build or improve for purpose of
sale.).
❑1,as Owner of the properly,am exclusively contracting with licensed contractors to --- . . . -
construct the project(Sec.7044,Business and Professions Code:)The Com ents's Li..
cense law docs,not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a comractor(s)licuued pumuanuo the Conmctoh
License La-
0 l am exempt under S.C. B A P C for this..on
Owner Dna
WORKER'S COMPENSATION DECLARATION
Ihereby a man under Penalty of perjury one of the fallowing declaratlom: - -
I haw and will maintain a Ceni ficom of Consent to self-insure for Workers Compact.
moan,as provided for by Section 37W of the labor Code,for Ne performmtce of Ne
work for which Nix Permit is issued.
I have and will maintain Workcri Compensation human",as required by Section
00 of the labor Code,for the performance of the work for which this permit is issad.
My Worker C pensaI(ion/IJna�un�nc�ecarticr end Policy numMre �s /
Cartier. l ly\"v-+sem'_] Poliry No.: �sJ 1 sp_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QTlsacnion wed not M completed ifft Permit Is for one hundred dollars(SIM)
or less.)
1 cenify Not in the performance of the work for which this Permit is III I shall not
employ any person in any manner an m to become subject to the Wo]mos Compensnien .
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.aner making this Cenificuc of Exemption,you OmW
become subject to the Worker's Compensation previsions of the labor Code,you must
�Q forthwith comply with such provisions or this permit shall be deemed revoked.
z 0 CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
Ye> the work for which this permit Is issued(Sec.3097,Civ,C.)
2w Q Under's Name
5 Z Lenders Addrem
J C) 1 ccnify that I have read Nu apfiction arta sate that the above information is
y P colica.1 agree to comply with all city and county onfinances and sate laws relating to
'nU building Coniwction,and hereby sumonne representatives of this City to cuter upon the
Na abovwmentioned property
oat fond cx cnrca purposes.
(We)agree m save,indemnify and kap harmless the City of Cupeniw against
ti h liabilities,judgments,costs and of
which may in any way acme against mid City
J z A APPLICANT
of did UNDERSTANDS
Of Nix permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH Issued by: Date
SOURCE REGULATIONS. �a®�Q�
f h �^�e_4 Re-roofs
stgnaar�pplrcan L�ontnc� ` Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle hvallous material
as donned by the Cupertino Municipal Codc.Chapter 9.13,and the Heal and Safety
Odc.Se ,ustion 25333(x)? All roofs shall be inspected prior to any roofing material being installed.
❑YesNm
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
t It haxodnm a
air conminm as dcnncd by the Bay Arta Air Quality Management all new materials for inspection.
❑Yts No
I have read the haxaNms ro mslals requirements under Chapmr 5.95 of Ne Califnr.
nia He llth&Safety Code,Section 25505,25533 and 25534.1 understand that lithe building
don not currently new a anent.Nat it is my numansihility in entry the occupat of Ne
requimm n et nor to issuance or a Ccrtifca u m
��` jC_ �3`�f�C /Q� Signature of Applicant Date
Owner Or autharixed agent `�/ Date All roof coverings to be Class "B"or better
1
CITY OF CUPERTINO 3
WATER HEATER °
CUPEkTINO PERMIT APPLICATION FORM
APN# 2 / 3 0 p� Date: G �
Building Address-
Owner's Name: r, / e /I �rPhone yLo
Contractor: // / Ph e: Licen e#:
Contactone: v
Cupertino Business License#:
017-L1 1 �US L,�w/ z i c�/"Q Y p
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: O
• Strapped El On Platform El
�j Bonded
New Location ❑ Re lacementp7
Qty
A ble Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
G8'