03100070 CITY OF CUPERTINO " r* ' W a°V
BUILDING DIVISION PERMIT CONTRAC POR INFORMATION
FO .a1`!W'
BU ILDING ADDRESS: HOT WATER INC PERMIT NO 03100070
OW NF.R'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
ALLAN MTT,T,P.R
HE (6110) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELF.LT PLUMB MF,CH
0 0 0 0
+00 LICENSED CONTRACTOR'S DECLARATION
1 wF I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
;sW with Secum7000).f Division 3m the Businavand Profession,COdc.and my license is
inout
ClaQs c,CI nd u Z WATER HEATER REPLACEMENT
��_ Liccn
ifs DatC O CuntLic.p
raclar RNA r5 /}a
As she I M use DECLARATION IYI\\VI/f/v[�\k �^
i z< I understand my plans shall he used as public records ( /
idu
°a.G LicensedProbsvionat NOV
X01 OWNER-BUILDER DECLARATION 4 ZOO
1<� 1 hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 11131.5 Business and Pmfesslons Code:Any city or county
which mquires a permit 10 consrua,alter,improve.Jcmalixn,or repair any.structure
priorlo its issuance.also requires the applicant for such Permit to rile a signed statement
]�a that he is licensed pursuant in the provisions of the Contractor's License,Law(Chapter 9 Sq. Ft. Floor Area ❑
jam$ (commencing with Section 7")of Division)of the Business and Professions Cade)ur
_ that he is eaempt therefrom and the basis for the alleged exemption.Any violation of 35628036 . 00
Section 71)3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(11500).
❑L as owner of the property,or my employes with wages as their sole compensation, T
will do the work,and the armhonr is Pat ntended or offered for sale(Sec.Sona,Business — FINAL jEggg� RcWaW'RGY
and Professions Code:The Confiai License Law dors not apply to an owner of
pfopeny was builds or int proves thercon,and who area such work himself or through his 506 — GAS TEST
Own employees.provided that such i mprovomenu are not ntended of offered for sale.If. 1107 — FINAL PLUMBING
however,fie building or improvement is sold within ane year of completion.Ne owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owner of the propeny,am exclusively contracting with licensed convenors m
construct the p deet(See 1044.Business and Professions Codc:)The Contractor's Li .
cease taw docs not apply to an owner of proper who Wilds or improves thereon,and
who consent for such projects with a eonvicar(s)licensed pursuant t0 the Contractor
License Law.
❑I am exempt under Sec. B k P C for this reason
Owner Data
7CamWORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of perjury,one of the following declarations:
have and will maintain a Certificate of Consent t0 sa f-iasu a for Worker's Compen.
n,as provided for by Section 37M of the Labor Code,far the perfmmance of me
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
ofthe laser Com,for the Performance of the work for which this peman is issued.
Worke' C 17;tttion lnsunarae carrier end Policy number aro l
cr: i11—b.��k'�OPolicy Na: I S ty �7Vy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QTis section need not Mcomplecd if the Permit is for one hundred dollars(11100)
or 1csa.)
1 certify Nat in the performance of the work for which this permit is issued.I shall not
employ any perms in any manner an az to become subject to the Workcri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject 10 the Worker's Compensation Provisions of the labor Cole,you must
foMwith Comply with such POvlamn,or this permit snail be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a mnstmction lending agency int the Performance of
:d > the work for which this permit is issued(Sec.3891,Ci,CJ
A Q Lender's Name
�• Lender's Addrets
D z
O 1 eenify that 1 have read this application and state that the about information is '
cone".1 agree to comply with all city and county ordinances and state laws relating to
V building Con]1Nction.and hereby anhorirc rePrcenlatives of this city to enter upon the
U slave-mentioned propeny far inspection purposes.
(We,)agree to save,indemnify and keep harmlcia the City Of Cupertino against
gI, liabilines.judgments.Coss andearere,which mor in any way accrue against mid City
J Z in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL
ALL/NON-POINT Issued by: Date
SOURQEREGy LAT��L 1 cl / '✓Jr✓ Re-roofs .
Signature of ApplicanrContracmr ate —
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hanrdous matenal
as defmcd by the COpeni nn Municipal Code,Chapter 9.12.and the Health and Safety
code.Section Yzss3xara C"a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
I
it harardus air contaminants as defined by the Bay Area Air Quality Managementall new materials for inspection.
udc! /�❑Yes I) .1 have mal the havardous materials requirements underChapter 6.95 of the Califor-
HealthASafctyCodC,Seen.25505.25533 ad23514.1 Ondcrstand thulithe Wilding
es not currently have u tenant,thm it is my Pap nsihility m nobly the eceapant of the
uircmcns n he me rmi53uan"enfaccmrlcateof Signature of Applicant Date
Owner ser suihonrCJ agent, le All roof coverings to be Class "B" or better
CITY OF CUPERTINO �7
awas WATER HEATER 03 1
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
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Owner's Name: Pho e :
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Contractor-&O CN W� Phon / /�9T S v License#��36lZ
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Contact: Phone: Cupertino Business License#:
Building Permit Info: /
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential/q Commercial ❑
Cost of Project: moi,
OStrapped ❑ On Platform El Bonded F-1New Location ElRe lacemene�3
Qty. .
A is e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
0