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34CONTRACTOR INFORMATIO`
BUILDING ADDRESS:
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ALL VALLEY PLUMBING
PERMIT NO.
05040131
OW NER'S NAME:
NNON OR
PERMIT ISSUE DATE
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INE,
SANITARY Nb.- 0 OL NO,
ARCHITECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
with Section 9DIIB) of Division 3 of N, Business and Professions Code, end my license is
in
lceose Cl snd�r' Jfl Lie `� �p
REPLACE WATER HEATER
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—17
ARCHITECTS DECLARATION
I understand my plans shall M used u public records
r/
Licensed Professional
OWNER -BUILDER DECLARATION
License Law for my
I hereby vSect Nat 11. exempt from the Cocoons
V
Code: Any city or county
Co
following nnson. (Section Wmote Businessandmpr
^J
a permit improve. der of pair any simulastatement
tlPer
alteo nt
which rots
issune.
ro iuims the for such Permit fie enl
pelt III IIScensnce,reurrit the Ireappheam fine
Ft. Floor Area
Valua[io
to Co mon'lefes Law (Chapter
(cam eningwitPSectionHOh,ofDiviomrfthe Comracori4ronsclaw(Cotic)9
Sq.
of Division] oftheegedrasand ProfessionsA.viGale)tar
li and the aura for the alleged exemption. Any vialn(on of
that he I, arewithon,fon and
Nat is exempt
3-49N brgW-F 00
Occupancy Type
Section 9o]L56yaundred inmfocs permit subjects the applicanuo.civil Penally of
io any applicant
p
not mom than f hundred dollar (5500).
I, u invi erof the property, or my employees with wages u thele sole compensatlon,
Required Inspections
will do Oe work, and Ne Swmum is not intended or offend for sale (Sce. 7044, Business
Slid Profession. Code: The Contractor's License Law docs of apply m an owner of
property who Guilds or improves Ihemod. and who does suchwmk himself or through his
own employees. provided that such improvements are not imended otoRered for sale. If.
however, the building or improvement is sold within one year of completion. the owner
builder will have fm burden of proving dust be did stet Guild or improve for purpose of
sale.).
❑ 1... Ievbe, of the property, am exclusively contracting with licensed contractors to
constmet the project (Sec. 9044, Business and Professions Code:) The Convector's Li.
cense law does not to an owner of progeny who builds or improves thereon, and
who contracts fol such projeCU with a eontractor(s) licensed pursuant to Bre Conuacoes
License Law.
❑ 1 em esempt under Sec. . B h P C for this mason
Owec Dna
WORKER'S COMPENSATION DECLARATION
1 hereby Mr. under, penalty of perjury one of the fallowing declarations:
I ham and will maintain a Certificate of Consent to selr-Insumfor Workers Cumpen-
snion, u provided for by Section 3](10 of the Labor Code, for Ne performance of the
work for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
,'M of the labor Cade, for the performance of the work for which this permit is issued.
My Work ea pensation Insurer e£urier and Policy number a
r
m�v+� ✓ �3l f
Canicry� Mn hvm Polity No.: 16
CERTIFICATE OF E%EM POCH FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($1 00)
or less.
1 cenifv that in the performance M the work for which this Permit Is issued, I Shell not
employ any person in any manner so u to become subject the Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Ccniliale of Exemption, you should
became subject to the Worker's Compeneeti ed provisions of the Palo Code, you must
forthwith comply with such provisions Or this Permit shall to deemed revoked.
CONSrRUCnONLENDING AGENCY
1 hereby affirm Nel mere is
30 lending agency Inn the Performance of
s ed (Sm.
me work for which mit Permit Is issued (Sec. .099, Ci¢ C.)
Name
Under's
Lender'. Address
1 certify that 1 have read this application and sum that she above information is
Correct. I agree to comply with all city and county ordinances and state laws relating to
Wilding construction. and hereby verbalist npresentatims of this city to enter upon be
ahnve-mentioned property for inspection PUTOWS,
(We) agmc m save, indcmni fy and keep hammers the City of Cupertino against
liabilities, judgments, costs and expenses which may In any way Scenic against said City
Ac�
in consequence of the granting of this Permit.
L
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REG LATIONS.
Re -roofs
Type of Roof
LC&
a;—
/
Signature of ApplicanVCourecter Dare
HAZARDOUS MATERIALS DISCLOSURE
Will IM applicant or from, building Occupant stare or handle havudous mnerial
as defined by the Cupenino Municipal Code. Chapter 9.12, and the Health and Safety
Code. S,ction 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or dcvlecs which
sh haaxsdous stir contaminants as def rld by the Bay Arca Air Gual'ny Menagcmcnt
all new materials for inspection. '
isvi,t9 I
❑Yes [3 No
1 have mad me hanrdous materials requirements under Chapter 6.95 of de Cali for
ria Health k Safety Clark. Sewuam 25N6,25533 and 255]4.1 understand that if the building
does not currently have a n.m. Net It is my rcspynsi hilly m nouly the }}}xx�scupam rel the
requirements, he met prior m'#uancc tufaCcnifca¢ b/Wpanry/'1
Signature of Applicant Date
rywhit/Mmust
/,6
All roof coverings to be Class "B" or better
ownmm.mdag�—
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CITY OF
�UPERTINO
0
OWNER'S NAME:
GENERAL CONTI
I am not using any
Please check applicable
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
ii1ding Department
PERMIT #
%UGi 3
PHONE # WY
/ FAX #
Signature Date
and complete the following information:
Date
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 ZF
Date
t
t
alon
CITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
o p � 01.E /
APN # 2� > n t•� /
Water Heater / Vent
Date: o Z
Building Add ?s
!
Plumbing Permit Issuance
PLUMBING
Owner's N e:
Owner's
Energy
Ph ne #:
Fg,7
Contract 7/
Phone:iv
License
Con
e:
Cupertino Business License #:
Building Permi fo:
Bldg ❑ Elect ❑
Plumb
Mech ❑
Job Description:
Residential 1 Commercial ❑
Cost of Project:
Strapped On Platform ❑
New Location ❑ Replacement
Bonded
Qty. if
ADnlicable Fee ID
Fee Descrintion
Fee GrouD
BPWHEATER
Water Heater / Vent
BUILDING
PPERMTI'FEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING