05020155CITY OF CUPERTINO
BUILDING DIVISION PERMITxCONTRACTOR
INFORMATION
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BUILDINGADDRESS:
A7 amqnm Air
HOT WATER INC
"5020155
OWNER'S NAME:
PERMIT ISSUE DATE
TONE:
SANITARY NO. CONTROL NO.
(650)298-8494
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'SuDECona
Job Description
ss of Chapter 9 (commencing
I hereby affirm that I am licensed under ofC Chapter
P
and Prof
with Sermon ]IXM)) of Division ] of the Business and Pmfcssiona Cook, and my license is
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� i«Ilkclaanderr r.36 Lie., .7 -3 ev
REPLACE WATER HEATER
Dam Contractor =
A CHITEL S DECLARATION
I understand my plans shall W used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afOrm that I am exempt firm the Contractors License Law for the
following moon. (Section 7131.5, Business and Professions Code: Any city or county
which requires a permit to cdnsomeL that, improve, demolish, or repair any structure
! prior to its ouncnce,atao requiresthcapptimet fareach permiuo rhe a signed statement
that M is limosed pursuant o the provisimu of the Comracmr's Umve law(CMpmr 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 or the Business and Proportions Code) or
that he is; exempt therefrom and the basis for the Jhcgcd exemption. Any violation of
'''jjj �FALTA�dI[IbCd Q
Occupancy
P y T ype
Section 7031.5 by any applicant for a permit subjects Ne applicant o a civil penalty of
not moa Nan fisc hundred dollars (S500).
_;A r
❑I,azownerof rhe propcny,mmy emploYces with wagesaz their sole eompenss0on,
fb
j
\\/ ,f � Required Inspections
will on the work and the structure is not amended oroffcmd for sale (Sec. 7041. Business
and Profestioo Code: The Contractors Licmue law does not apply In an owner of
pfopeny who Wildsor improves dtemon.and who doessuch wok himself,(through his
own employees, provided that uch improvements arc not intended ora@red formic. if,
however. the building or improvement is sold within one year ofcompimon, the owner-
builder will have the burden of proving Nat he did not Wild or improve for purywm of
side I
Q I, as owner of rhe property, am exclusively contracting with licensed contrmmrs in
consumer the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
muse law des not apply in an owner of property who Wilds or improves themon, and
who contracts for such pmjcm with a cormucmr(s) licensed pursuant to the Contractors
License Law.
Q I ore exempt under Sec. . B k P C Tor this barbed
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Owner Data
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WORKER'S COMPENSATION DECLARATION
1 hereby nRnn under penalty of perjury one of the following dechmarions:
E] I have and will maintain a Cenificaeaf Coescnr to self -insure for Worker's Comped -
ration, az provided fw by Section 3700 of the Labor Cade, for the performance of the
work mwhieh this permit is issued.
I have end will maintain Worker's Compensation Insurance, o required by Section
37W of Ne Labor Code, for the performance or the work for which this permit is issued.
My Workers Compensaari�on Insurance carrier and Policy number are�T
Cartier. : !; Fsl K� Policy Na.: /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mos mesion need nm becwnplced if the permit is for enc hundred dollars (gaol
less.)
I ceni fy that in the performance of the work for which this permit is isaacd. I shall not
employ any person in any manner an ter to become subject m the WorkCR Gmmixentation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Worker's Comperwtiow provisions of the Labor Coati you must
foMwith comply with such Pmvisido Or this permit shall W deemed mated.
I
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a Construction lending agcnry for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
1 certify mat 1 have tend this application and sum that the above information is
correct. I agree to comply with all city and county ordinances and some laws misting in
and hereby authonae reprrxnutises or Nu city m enter upon de
move-menowniog
pur,c
ahove-mcnudgm ntoleny for expenses
(WO agree m save, indemnify and keep harmless the City of Cupertino against
Iiacoiseq juceofthecosuand of which ms
which may in any way acerae against said City
m consequence of the Bradllag Of Ibis permit
this
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOP C�,REGULATIONS.�./
f�
Issued by: Date a L Ak/
/`^tel K/V
Re-roofs
Type of Roof
if Lyd f i/.. t o i'td -,11 3
Signature of Applicant/ racer Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle harardous material
defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
We, s 25532(,)?
0Yer P111.,
All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building oats ant use a or which
Pn s P
If a roof is installed without first obtainingan inspection, I agree to remove
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mit ha menus ear contaminants o JcOncd by the Bay Area Air Quality Management
quip a
all new materials for inspection.
Disuia?
❑Yes En No
I have mad the hazrddus materials requirements under Chapter 6.95 of the Cali for
& Safety
nine Health &SafmyCve. Sccuonsntoiti2myrsmd2floloy unenurW to
0 55 3 25514.1 Wilding
/u/? _ �.
/�!/
does not have a Swam. the it and top
un notify the pant of dtc
l_/1/ `�✓s�' _A\J ✓"✓iCiYl��. O
retomancrits, which mast ter p��or(yaissuancc of a Certificate of cc man=
Signature of Applicant Date
"" 3
All roof coverings to be Class "B" or better
1
Owner tar authomcd teem pantw
CITY 0,
QUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
v VY 7 /,3-71 so )n
PERMIT #
o SCdao/
OWNER'S NAME:
PHONE # d —� f0 - 7 i
GENERAL CONTRACTOR: /
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
SUBCONTRACTOR 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
Plumbing V- /I
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
02—
Date'
2Date
e
Owner/ Contractor Signature
SUBCONTRACTOR 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
Plumbing V- /I
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
02—
Date'
2Date
0
A
- CITY OF CUPERTINO
WATER NEATER
CUPEkTINO PERMIT APPLICATION FORM
APN # / ! /
3112
Date:
Building Address:
PPERMTCFEE
/()qSd rl
PLUMBING
Ow�� /�� /C / s l
Phone
Contractor: Phone:
License #:
76�
Contact: Phone:
C,12 yr s62Co31-WY5
Cupertino Business License #:
a /Z�i
Building Permit Info:
Bldg ❑ Elect ❑ Plumb C9
Mech ❑
Job Description:
Ejc�r
Residential Commercial rl
Cost of Project:
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Re lacement
Qty. if
ADDlicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMTCFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING.
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