05020154CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION y:.
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BUILDING ADDRESS:
9R41 RAYWOOF) FIR
HOT WATER INC
PERM"'15O2O154
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
650 298-8494
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� I�
LICENSED CONTRACTOR DECLARATION
Job Description
1 affirm I am under, provisions of, 9 (commencing
P
P
Dthativision Cm
with Scctidn ]akq of Division J of Nc Business and Pmfcssiuns Codc, and my license is
imiWncti,70 ofBri
Io n
Fon Force and effect. Lk.g :3
License Cl s 7
REPLACE WATER HEATER
Contracmr
ARCHDELTS DECLARATION
1 understand my plans shall be used u public mcnrm
Licensed Pro( .. mil
OWNER -BUILDER DECLARATION
I hcmhy affirm that 1 am exempt from the Contractors License Law for Ne
following reason. (Section 7831.5. Business and Pmfua ns Code: Any city or county
which requires a permit to construct, alter. impmus, demolish. or repair any structure
prior N its issuance, also requires the applicant for such Permit to rile a signed statement
that he is licensed pursuant 10 the provisions of the contractors liccnm Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section ]000) of Division 3 of the Baglow and Predications Code) or
Nal be as exempt therefrom and the hasis for de alleged exemption. Any violation of
314aWl'Qu1&ei0 O
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nal more Nan five hundred calla.. ($500):
wlthwageau theirs..
❑ Luowncrk,
ridthe nattirearmtimoyeu
donde (Sec. ]OIG, Business
will work, and the isnot sounded or 0414.8 sins,
Required Inspections
Pr fie he Con law does not apply N an owner of
The Contractors Law do
and Pmfcasiobu
builds or ndwho does such work himself his
enywho buildsorimprovesch
ilNmugh
impr,andwho
own Natsuchim me
own employees, ,
ear combed, foe sale B,
withes
oridcd
due buildingis mid in one of the owner,
however. Ne Dvethe orimpmvemcnlissoldwithinone year of mprove
for
will Asa Ik buNen of proving Nat k Oitl not Wild or improve fur puryose of
ghe.1r
salol.
a,`�\,
❑ 1, as Owner of IM property, am exclusively contracting with licensed ma.=. to
.t—"• f'r
coutmet the project (Sec. ]Ilii. Business and Profession Code:) The Contractor's Lt.
cense Law does net apply m in owner of propenY who builds or impmms daemon, and.who
conuacss for sash projects with a conusmr(s) licensed puuvanl to the CommoahLicenm
law.rIE
❑lam eacmpt undo Sce. ,B&PC fm Nis retia..Owner
Dao
WORKER'SCOMPENSATIONDECLARATION
I hereby of ire under penalty of perjury one of Ne following declaration:
i
Q I have and will maintain a Ccnilicale ofConscat to.self-insumrorWorkcr'.aCompcn-
ration, u provided for by Section 37W of the Labor Code, for the Performance of the
wark f r which Nis demist is iuucd.
Aave and will maintain Workers Compensation Insurance, ss required by Section
3]00 of the Labor Code, for Ne pcdmmuce of the work for which this Nmlil is issued.
My Workers CampensyaOZ insurance ca er and Policy numbeber are'
Carrier. rL[:'_ Policy No.: /!� a
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ohisaccsim recd not M canpleted if Ih permit is for one hundred dollars (5100)
or less.)
I mnifv Nal in Ne Performance of she work for which Nis Permit is issued, I shall not
employ my Night in any manner so as in become subject d the Wmkers' Compenatian
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Cenificau of Exemption, you shwld
become subject In the Worker's Compensation provisions of Nc Labor Code, you most
forthwith comply with such provisions or this Permit shall be deemed mvakcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a convection lending agency Ior Ne performance of
Ne work for which this permit is issued (Sec. 3097, Ci, C.)
Lender's Name
Unders Address
I ranee that I have rod this application and sac¢ Nu Nu seatabovel information to
1 ague to comply with all city and county colognes and seat laws m
Of r Upon
builds..gmnswdpro,ond herebyautho.do,sttacs. iuesafNisCity to enter upon the
building
above rteindiction Purposes
tianre
(W to save
(We) qui to save, indemnify and kith harmless the
OC of Cupertino againstCty
G/
expenses which may in anywaYaccrue againmsaid City
y
in Coitiesunce of thecosuang
of Negr TAN of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON
A APPLICANT
L \/
Issuedby: Date
-POINT
y rL J\
SOURC REGULATIONS. - ,/� /
Re -roofs
Type of Roof
� A,1_4N'— f/-� /
SSI ort of ApplicaD1 Dao u
US MATE RIALS DISCLOSURE
HAZARDOUS
Will she applicant ser fMuni building bad eH�uusmaterial
e. Chanumecor
dcfincd by Ne Cupeninn Municipal Codc. Chapter 9.II, and the Health and Safety
Z Section 255]2(a)?
All roofs shall be inspected pr to an roofing material bei..
P Y being installed.
❑Yea pwn
P g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Disoict7
❑Yes U -N.
Ihave mg! the hvScCums
rChaped6.95 done Wildin
add
nus Nicol" Balmy Cade, Sections i5, 5534.1 Wining
55rialsre33
occur
docs not cunentlY haus a tenant Nal il'Is mY Ir-aponihililY to ^alifY the occupant of the
I, is i5JJspo255JG.l to .6(y
isi� cif cA
req`rocntswhich mug Wmepan mmipasecofaeertificae, `
e
Signature of Applicant Date
All roof coverings to be Class "B" or better
atonic
or admddvcd agent WHO
`•J
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:/� cusp/
PERMIT #-,^ /
OWNER'S NAME: _-�IM p n
PHONE #
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
60
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
f e M L
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
Date
0
J
CITY OF CUPERTINO
4 WATER HEATER
CITCUPEI�TINO PERMIT APPLICATION FORM
0Sia0ts,
APN # ,Fj / — 07S
(� �J 2 0 lJ
Water Heater / Vent
Date: OS/
Building Address:
3 wdv�C 0� C�
s�i
Owner' Name:
�l ovi w
BENERGY
Phone #:
X08- M -377
Con actor: Phone:
/ f r
License #:
-7&3wa
Contact: Phone:
C41lr(S
BUILDING
Cupertino Business License #:
t(,:s k,7
Building Permit Info:
Bldg ❑ Elect ❑ ._.Plumb Mech ❑
Job Description:
t!�? Alc&fev
T7- /0 fz�
Residential Commercial ❑
/—/ Di
Cost of Project: 500
Strapped ❑ On Platform ❑ Bonded ❑
_._ ___ _
New Location ❑ Replacement
Qty. if
ADDticable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
/ PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING