05040183 CITY OF CUPERTINO 7�'" ' ''
BUILDING DIVISION PERMIT �(CONT�RACTORANFORMATION R
BUILDING ADDRESS: PERMIT NO.
WATER HEATERS ONLY 05040183
("AR01 I R9 IDR OW NER'S NAME: PERMIT ISSUE DATE
NE: f SANITARY �ftOL NO.
RCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
(_� 0
:00 LICENSED CONTRACTOR'S DECLARATION Job Description 0
s C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
n<i with Section 7")of Division Sof NC Rusin m iso ca;' m e,utdTerns
-��
in Off . Z4.:-.REPLACE WATER HEATER
O Dam 3 0
ARCHITECTS DECLARATION
C< I understand my plans shell be used az public records
;off Licensed Pmfcssinnal /
a atIa.OWNER-BUILDER DECLARATION
1 bertso .ittromsect that 1 1. exempt sad the Contractor
Co License Law far the
�po following muoe.(Scction]ln 1.5,Business and Professions Code:Any city at county
x m which reyuims a permit In ennslmet,alcor.impmve,demolish.Or repair any summm
a poor to in issuance,arm requires the applicant for such permit to file a signed suamcnl
?6
that
commecing wit pusvvnOO We ofprovisions ionf thee Business andPoclaw(CMpar9 Sq.Ft. Floor Area aUat10
y F 0 (commencing iS rag ort Section7000)add to basis
3 of the alleged
ximpt Professions Cod]mon or
of
y that Section
a exemps tang applicant
p li and the aper it Ne alleged eumant to Any violation of
sor...ovs by any ao for 500). sobimu the applicant m a civil Penalty of 3 �1er0 0 Occupancy Type
' not mom Nan Ovc hundred dollan(5500).
1,az owner of die property,or my employees with wages in their sole compensation,
will do the work and the atunure r nos intended or offend forsa4(Sec.7044,Business
and Prefectures Code:The Conlrectors Lt pe Law dooat apply w an owner of Required Inspections
property who builds or improves Ihemon,and who does such work himself or though his
Own employees,provided that such improvements m not intended or offered for sale.If,
however he building or improvement is sold within one year of completion,Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of the progeny,am exclusively convecting with licensed contractors to
construct We project(Sec.7044,Business and Professions Cade:)The Contractor's Li.
cove Law docs not apply in an owner of property who builds or improves heroin,and
who contracts for such posters with a eonuanm(s)licensed pursuant to the Contactors
License Law.
I am exempt under Sec. .B&P C for his reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hcmby affirm under penalty of perjury one of We fallowing declarations:
1 have and will maintain a Certificate of Conscnt to self-ivum for WorkersCompen-
satian,az provided for by Section 3100 of the Labor Codc,for t perfmmme aof Ne
w rtfor which this permit is issued.
ban add will maintain Worker's Compensation Insurance,as aquimd by Section
37 of the Labor Code,for the raformance of the work for which this permit is issued.
My Workers Com vationln senna carrier and Policy number arc: ,I �s
Cartier. S Policy N..;55S 0 _3"D
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit is fmonc hundred dollan(SIM)
or us.)
I certify this,in thc performance of the work for which this permit is issued.I shall nut
employ any person in any manner x u to become subject o lM Workers'Compensation
Laws mf California.Dam
Applicant
NOTICE TO APPLICANT:If,after making his Cedificam of Exemption,you should
become subject 10 We Workers Compensation provisions of the Labor Code,you must
.,Z, foMwilh comply with such provisions or this permit shall be decmcd invoked.
Z O CONSTRUCTION LENDING AGENCY
[r Ihcrtby affirm that Wen is a crossunscron lending agency for one perfufinene,of
a > IM work for which this permit is issued(Sec.3097,Civ.C.)
1 A Tondos Name .
= Z Under's Address
Address
O 1 cenify that 1 have read this application and shote that the above information is
U. P Cartmel.I agree he comply wit all city and county ordinances and suite laws slating to
0U building construction,and hereby auditins mpresenutirxs of this city to enter upon the
[Il ahove-mentioned pmpvny for Inspection purposes
(We)agar to save,indemnify and keep barrel.the City of Cupertino agi ivl
f req
liabilities.judgments.casts and expevu which may in any way accme against soid City
U Z All 11CA19 o ERgm ng ShrN WILL PL LL ON-POINT Issued by: Date
SOURC
4 291✓5 Re-roofs 07
Signawm of Applicanvconwcmr Dole
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant more or handle hazardous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Hcallh and Safety
me.seedansss" , All roofs shall be inspected prior to any roofing material being installed.��
Will the applicant of future building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit havardous air contaminants az defncd by the Bay Area Air Quality Management all new materials for inspection.
Districtf7 `
Yci
1 have mad the hvardoos materials requiamcnts under Chapter 6.95 of We Ethicr-
niaHcalth&Safely Cede,Snctiov 25YI5.25533 and 25534.1 understand thin ifthe Wilding
docs not currently have a umma.that is as my mspopeibiloy W ands y one occupant of the
requirements or pit mid. ancenfaCerifieateof apaney. Signature of Applicant Date
Owner per authorised agate me T is All roof coverings to be Class 'B" or better
�., Community Development
I\r 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
6UPEkTINO -
Building Department
JOB ADDRESS: l / L PERMIT #
05 q d l 83
OWNER'S NAME: ✓ PHONE # 7 3 -03 6
GENERAL CONTRACTO • FAX #
I am not using any subcontractors: 0 ate., �4 . bl -C!2;) 4 0 5
Signature T— 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
G!/� �� � • � Q 9� Y 14 cLS
Owner/Contractor ignature Date
04/28/2005 22: 54 5105383282 LEGALITIES INK / PAGE
01
5 CITY OF CUPERTINO Bonita J. Jenkins
WATER HEATER North
a41Per i
ts
CUPEkTINO PERMIT APPLICATION FORM
APN# 3f / 13 u Date: l Z 9 o S
Building Address: /O l t la C c." Z,�- -
Owner's Name: � Phone X73 036 Lf-
Contractor: 9 Phone: License#:
G+/4� M 800 8'35 -S 9 9 3714S7 -3 ,
Contact: Phone: Cupertino Business License#:
�6- Sa- 0. — S9 8 G
Building Permit Into:
Bldg ❑ Elect ❑ Plumb t2f Me-ch ❑
Job,Description:
Residential Commercial ❑
Cost of Project: od
9so , '
Strapped . ❑ On PlatformEl { Bonded ❑
IkN�cwLoca�tionn_Re Iacement}"
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING,
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
z�s � �