06010083 / CITYOFCUPERTINOgar.. :
BUILDING DIVISION PERMIT -`C1�1T.R'ACTQI2.I1V �RMA,TIOhI "
BUILDING ADDRESS: SOUTH BAY PLUMBING PERMRNO.06010083
1200 CANYON 0AN WAY
OW HER'S NAME: PERMIT ISSUE DATE
UNMESH AGARWALA 441 N CENTRAAVE01/17/2006
NE: SANITARY NO. CONTROL NO.
(408) 370-3535
ARCHITECT/ENGINEEN: BUILDING PERMITINFO
BO EO PL MECH
O
300 LICENSED CONTRACTOR'S DECLARATION
rd I hereby affirm Nal I am liaucd under provisions of Chapter 9(commencing Job Description
Z1 with Section r0(or11 Dividers 3af the Hualneu and ProfnoouC end Hensel'
lomA.Cloeedercec1�. gj � REPLACE WATER HEATER
License Chis L.-e�� Lie.
Delc t I Contractor v".J a
`
ARCHITECTS hall h use DECLARATION
tt I undcraund my plea shall he used AS public records �/���
;n Licensed Pmfcssional //
OWNER-BUILDER DECLARATION
f('J
0 S I hcmhy.AffirmSect on I am exempt Isom the feanuanafs e:Any
Lew for the
D1 Og following mason.(Sadao 703 1.5,Business and Improve,
de ons Cade:Any tiny or county
which its issuance,
a permit re cnuwcl.alar.Improve,tic ermit t,or e a sig ed structure $700
�y war heor inI tsiensedpalso
suntto Meres reisionofthent for Cosuch pctor'noices Law(Chapter
FF< Nernem.higwdPursuammM)m`Disiouofth'UnB.Mosent. dProwaw(C ode)., Sq.Ft. Floor Area Valuation
3S (comm aexe pt Section fmm a00th bands fr th the Bmineu ration.My
Cade)of
that ha k exempt dtemfrom and tiro bum for the alleged exemption.My violation of
Section 70713 by any applicant for a permit ubjau Ne applicant to a civil penalty of
not memun dfive hundred dollars(5500). P Occupancy Type
❑h u owner of Ne pmpeny,or my employcu with wager u Weir mle mmpeuatlon,
will do We woda.and the evumum is not intendedorolferod forsale(Sec.TON,Buonns Required Inspections
and Profeunsm
lons Code:The Cormier,License Law don not apply an owner of q P
Property who wildsnt improvesnhcmon,and who doenuchwork himtalforthrough his
awn employcn,provided than Such Improvements are not ntended aroRemd for Sale.If.
however,The Wilding or Improvement is mid within one you of completion.the owner
builder will have the burden of proving Our he did not Wild or Improve far purpose of
ante.).
❑1.as owner of the property,am exclusively convening with licensed conuaclors m
consumer the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense law does nut apply in an owner of propeny wbo Wilda at improves Mentor.md,
who contracts for such projects with Aconvacmr(s)licensed pursuant m the Conuseuar's
License Law.
❑1 em exempt under Sec. .B&P C for this rcuon
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby offmn under porosity of perjury arc of the following dalamdou:
1 ban and will maintain a Cemfimm of0mou nt m self-Iuum for Wallace,Compen.
7[31](0
on,u provided for by Section 7700 of We labor Cede,for tits performance of the
rk for which than permit Is Issued.
I hove and will maintain Worker's COMPensadon Imunnce,u required by Section
of the labor Code,few Ue perfmmaac of the work for which this permit is issued.
Warkefe Cnm,,((��n Ian lnsunnce tarsier end Policy number am:
mer (✓7' Policy No.:Ws<r Th 2'C 004o)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rbu section need trot W ccmpleted If Ne Permit Is fmone hundred dollen(SIM)
or leu.)
1 unify than in the performanm of We work far which this permit Is Issued.l mail not
employ any person In my manner an As to bcnmembject to the Worloc i Compeua0on
Iowa of California.Dean
Applicant
NOTICE TO APPLICANT.If,after molding this Certificate of Exemption,you should
become subject In the Wark $Compeuadon provisions of the Labor Code.you muni
.JO foMwith comply with such provisions or this Permit W deemed revoked.
r~yiCONSTRUCTION LENDING AGENCY
[.w I hereby affirm that Own H a construction lending agency for we perfurmence of
the was for which this permit Is Wucd(Sec.3097,Civ.C.)
Q Lender's Nurse
.`3 z Lcndere Add.
V Q I comfy Nu 1 have mad this application and come that the above Information Is
gL corms.I agra to comply with 41 city and county ordinances and sum laws mining to
Q building convection,and hereby auhorim mpresennatives of Nb city to enter upon the
{1) above-mentioned property for inspection ptuposes.
(We)Rime to Save,indemnify and keep harmless the City of CuPCnino against
y limllitim judgments.cone and expeuex wit' In any myattme agalnstseid City
Y, in consequence of the granting of this pe t. n
APPLICANT UN RSTANDS AND ILL MPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE ONS.
3
1cL, / LV44- - 1 204- Re-roofs
Signuum of ApplianUConumo r Dail —
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ar future Wilding=upset nam or handle haurdous material
AS defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
ads,Section 255330)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu Tu
Will the applicant or future Wilding Occupant vac equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants As,defined by the Bay Area Air Quality Management all new materials for inspection.
Disvict7
❑Yes -0-No
I have mW We hanho"materials env umkrChapme6.91ofthe Califon
ria Health&Sato Code Smdau255D5 533 25534.Iunleraurdthatirte Wilding
does not core ve rot.Wt i n my nobility m notify the occupmt of We
Y g
mquimmen u&Wmet m' a of.Certificate of Qeu cr. Signature of Applicant Date
�.1 / G 2`' ^7 I All roof coverings to be Class"B"or better
Owner or autbodned agent Dam g
Community Development
10300 Torre Avenue
1 Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
al ZOO C9N 0--1 06'0100d--7
OWNER'S NAME: U N ^1 L S I v9T21.uy PHONE # 6 J _ 3 -
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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
Roofing .
Septic Tank
Sheet Metal
Sheet Rock
Tile
7I-06
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER O C)
CUPERTINO PERMIT APPLICATION FORM
APN# � O� ( Date:
Building Address: \
a. I ZD b CAr►ti o N (9 Me, c�
Owner's Name: Phone#: 2d'�
U n1" �S H- /� H2w�1 6J7 go'I T
Contractor: n Phone: Licens #
uJi�-� 'Jnf-I �w��' ��v y�: 3 )j3J ,7j (
S
Contact: Phone: CupertinoBu mess Lice #:
�.L c�-tC� �G c�� � � -),J � Z�L` 0 Me
Building Permit Info:
Bldg ❑ Elect 0 Plumb Mech Lg/
Job Description:
Residential C' Commercial El
C`�
� uJILuN9�2 nggvavfc ,tiitcl �/I ��/i�1
Cost of Project: / 00
Strapped On Platform El
• Bonded New Location ElRe lacement.�{�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
4
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