05110097 CITY OF CUPERTINO
BUILDING DIVISION PE 'R .QIY
IQRMATI
✓, try Y 4 `''s`F k i. .r�1,1w'F 4-mf
au1LDINGADDRFSS: WATER HEATERS ONLY Pom'T"°'05110097
10902 CANYON VISTA DR
OWNER'S NAME: PERMIT ISSUE DATE
RICHARD DIVON 970 E. MAIN ST, SUITE 200 11/17/2005
NE: SANITARY NO. CONTROL NO.
(800) 635-5946
AR CHRECDPNGINEER: [t IIDINO PERM TINFO
((� PLUMB MECH
is LICENSED CONTRACTOR'S DECLARATION lob Descriptio
1 hereby a01m that 1 Am licensed mokr Provisions of ChaPlm 9 mammsming
HthSatim 70(116 ofDivWon3af the Butlmss uulPmtc�do aCode.sM mylkenack REPLACE WATER HEATER �� b A3in fall farm �] 1Q
6 rs -J
y Cl License aS• Lk.k
SS
Dam
646 ARCHRE D IA ATI qqq
I uMetwd my plana tIWI be used as public recortls
hc� LicensedPmfauanal
OWNER-BUILDER DECLARATION
�
1 hereby afnm that I Am Attempt from the Conuanah Ilecnw Law far ted
O o fallowing moan.(Section 7031J,Business AM Prefmsfons Cade:Any city at aunty
Sig which mqurea A pamout le contlnm,alum,hnprave,demolish,or repair my sm mum $1200
-iy priamitsissuance.usomquiresneapplicantratsuchpermitm0leuigmdstatemcm
thaFt.Floor Area Valuation
< t heulicensedpursuantA,theprovisionsofineContrectarslicenmlaw(Chapter9 Sq.
5EZn (commencing with Section 700M of Division 3 of the Busiws and Pmfaslam Cade).,
[ tiut an it aanpt tharemm and the hub far the allow.•-^ptiom MY violalon of
Section 7031.3 by any applicant fa A permit subjects the applicant in A civil penalty of eT Occupancy Type
tet mom than ave hundred dollars IS700).
❑I,a owner of ted Fop".or my employees with wages u thele solecampensstion.
will On the we&ad Ilan muchm is not intended Or Offered faraaW(Sec.7044,Bufineu Required Inspections
and Pmrannom Cade The Contactors Lkeuse Law data tet apply m An ONAM or q p
prapmywho builds or improwas Wersom.and whodoesfuchwork himselferIbrough his
awn employru,provided that such improvements art notlnurded Atoll forsale Ir.
hmvever.Ne building a Improvements is sold within am year of compkdm,the Ower-
builder win love the burden of pmving that An did tet build or improve for purpose of
ole.),
0 1,As Owmr m the pmpeny.am exclusively eobacting with Ornued mnuacmn m
Construct the projea(Set.7144.Business and professions Coda:)The Contractors U. _
cause Law dna not apply At an Ammar of propertyivis,builds of Winans Ihemm,aha,
who contracts for such project,with aanoactar(s)licensed punwnt m IlseCmntracmr's
Llttme law.
❑Iameaemplunde See ,BAPCfarthbmamn
Owmr Dam
WORKER'S COMPENSATION DECLARATION
I hereby a117rm under pensluy of perjury am of don fallowing declandmu:
1 ham and will munuin a Ceelncele ofcoment in telt-Insure fm Workers Compen-
wion,as provided for by Section 3700 of dm labor Cede,fa the performance of the
wok for which this permit Is issued.
I have and will maintain Workers Comp rnalan Insurance,as required by Section
] of the labor Cede.for Chat performance of thn work fm which thio permit Is luted.
My Warrkm�q�rT�aas.Csol`rLL`peyysee//yya homes anis and Policy
vnutmb��s••��am��:
Grrier.[�Q — Policy Nol:��-gtI �1 ,
CERTIFICATR OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Oris seeelm sued Out W ampkxd Him permit Is foam hundred donan(S I00)
Ar leas.)
I certify that in the peto namA of the wart for which this permit k Issued.l shall not
employ any person in my manmrro As At became subject to the Waross'Cmnpenssdm
Laws of Caiifomis.Date
In ant
NOTICE TO APPLICANT:If.afte making thisCen Elam of Emmpdon,ym siseu5
bosom Subject to the Warmers Compensation provisions of the labs Code,you mut,
.J O fol with comply with such provisions a mu Permit MAJI W domed ranked.
Vy
CONSTRUCTION LENDING AGENCY
(=, 1 hereby suinm dot ft.IM us
a cauuction lending agency Ire the performance,of
D:> the work sur which this remit is issued(sec.3097,CN.C.)
ul. Lenders Nmm
0. .Z Leader:Address
U O 1 certify that i haw:ted this Applicatim and slam the the above Information is
Ly !' c=Id
rteCt.1 agrte an camplY with all city and counh ordmanaa am sore laws reltling m
O bis Iding canatmnioq and Aereby authmire repmmnMUM of this City to entre upon led
L37 above-mentioned pmpeny for Wpetim purposes.
(We)aI=m Ave.Indemnify and kap harmless the CITY of Cupertino against
Car! Iiabilitia,jdgments.eau And Capetuta which may In my way accmO gminn laid City
Uz in caAm As of the nntinl of this
prem
r"' APPLICANT U STAND N L COM WIT(ALL Nl��I� Issued by: Date ��
SOURCE EG ONS. Y(
Re-roofs
Signature OfAppli<sO Oate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the suppliant or future buildingilding aecupant sure or handle hamdoanmaanriai
As
lDwict?de0md 6Y tise Cupenim Municipal Code.GaPanr 9.12.aha the Health and Safety
mit.Section 33733(4)7 All roofs shall be inspected prior to any roofing material being installed.
[3 Y. Na
Will f applicant or future building occupant use equipment a devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit locardaus air cone alnuma a donned by the Bay Ana Air Quality Management all new materials for inspection.
❑Ya ❑MR./I have and the hmarMmsmaurisiarequlnments underChapterd.95 ofNeCalifor•
mund tht lithe building
ant or theyolremc w a' ttadfDecapan Signature of Applicant Date
I1�7�os All roof coverings to be Class"B"or better
Owner or tuthorimd a cnt Dau' '
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
tPEkTINO
Building Department
JOB ADDRESS: /0 ;FU Z PERMIT # 0.5 11 OC)
OWNER'S NAME: V PHO
GENERAL CONTRACTOR. FAX #
I am not using any subcontractors:Qab�1 xals,. OhQ, !/ / d S
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
C WATER HEATER
CUPEVINO PERMIT APPLICATION FORM
APN# 3Y-6/ Date:
Building Address: 90 Zl (�
tri- (J c., [U•t .
Owner's Name: Phone#:
jv9 - /z 8'
Contractor: Phone: License #:
FOO 8,35 -5c?,/,6374573
Contact: Phone: Cupertino Business License #:
a, / 5�G
Building Permit Info:
Bldg ❑ ' Elect (2 Plumb Mech
Job Description:
Residential Commercial ❑ �i e
Cost of Project:
/Zv o
Strapped 13 On Platform Ll Bonded 11
New Location ❑ Replacement
Qty. if
Applicable _ Fee ID Fee Description Fee_Group-___
I BI'WHEATER Water Heater/ Vent BUILDING
/ PPERMITFER Plumhing Permit Issuance PLUMBING
1 BENERGY Ener BUILDING
BUSLIC Business License BUILDING