03060124 CITY OF CUPERTINOPERMIT
BUILDING DIVISION 'k�a.-'•us 4� Ta�-RINr1:0„:.%.
BUILDING ADDRESS: """'03066124
ERMITNO.O3066124
9;'94 CARTA 21-A1412A ST
'
OWNER'S NAME: PHRnffI ISSUEQAJ/ 1{( a/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB
MECH
30p LICENSED CONTRACTOR'S DECLARATION
5FF,j 1 Internal,afDrm dual I un Ilmm ad under provisions of Chapter 9(temmeming Job Description
with Section 7000)of Division 3 oftie Business anfes
d proaiuu Cme.and my amuse 6
on mmBto.ande@a WATER HEATER
i Tf Like, Clan Lk.N
' Q Dam Convector
ARCHITECTS DECLARATION
,5555 ffyy33 1 understand my plane Ntll ba used u public records
5 Licensed Professional
c
u OWNER-BUILDER DECLARATION
i 2 1 hereby affirm that I am exempt from the Conlncmfs License Law for the
o O following mason.(section 703 1.5,Business and Professions Code:Any city or county
9 which requires a permit m comruct,alms boprom.demolish,Or repair my mucture
19'
n prior m its issuance.also require,the applicant for such permit to file a signed statement
Z
< duo heklimvwpumanttoOmprovisiouoftbeCmuscmfeLim.Law(Chapto,9 Sq.Ft.Floor Area �Y�Im�ion
� (commencing with Section 7000)of Division 3 of tie Business and Prefestimu Code)err
3 8 OW he B unapt Lkmfmm and the bask for Ne alleged eumpuon.Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 A8ffi Milti5er 0 0 Occupancy Type
not more then R.hundred dollars f$50H,
❑1,as owrmr of the Property or my employees with wages as their role compensation.
will do to work and Nemnchem lana invaded nr offered forsale(See.7044,Busircu —
and Profmodou Code:The Comracter's Lionise Law does not apply to an atom of c
Property who buildsarimprovea tMmun,andwho dmuuch wank Mnuelfarthreugh his 506 — GAS T
EST
Own employees,provided thalwch improvements are natlnuended aralfemd for sale.if, 507 — FINAL PLUMBING
however,thebuilding or Improvement s sold within one year of completion,Ne owner.
Wilder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1.as Owner of the propenY-am eachnively con reming with limned mnurttmre On
common the Project(Sec.7044,Business and Profession Code:)The Convactoh LI.
roue Law does not apply to an owner of propeny who builds or Improves the char.and
who connects for such projects with a comame(s)licensed pumuam to the Commutes
kens Law.
l am esempt dmBdPC(or Chia n
o -1
WORKER'S COMPENTA_T1dN`5ECU_jbrnON —
1 hereby affirm under penalty of perjury one or the following declentions: U /, �
I love andwillmuntainaQNOmmofCen¢mmulf-Iuurt fm WadmM1Campen- 4/I/J///
salon,a provided for by section 7]00 of 1M Labor Code.for the perfo,mana at tic
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Instusnm,u required by Section
r
)]Baal Ne Leber Coda fm No performance of tits work for which this pamlb k Isaund,
My We
Compensation Insurum artier and Policy number tie:
Comm Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thksectlon need not M completed Hthe permit Isforom hundreddultsn($1010
or IesaJ
I certify Nat in tite performance of the work for which this Permit is Wood,I doll not
employ anyperem in any manner an as an Mame,abject ve tie Worten'Compensation
Laws of Califamla.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workefe Compensation provisions of Ne Labor Code.you must
.)O forthwith comply with such provklou or this permit shall be dmmed moked.
Z'M CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat them ver coutucam lending agency for Me pcoro rmamc of
7G the work for which Otis permit Is issued(sm.309].Civ.C.)
1 Q Lender's Nam
7 z Lender's Addles
;)O 1 certify wt 1 have read this application and auto that the shove inform W m is
Ecorm.l agree to comply with all city and county adinanms and sum laws relating ve
O building construction,and hereby suthodm repmxnutivea of this city to enter open Me
0. above-mentioned PMPcry for Wpection ParPosea
(We)agree to save,indemnify tad keep harmless the City or Cupertino against
ti H Ilabillties.judgmenu,costs and expenses which may in any way acme against said City
;)7 in consequence or the jumung of this permit
a7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-PO NI' Issued by: Dat
SOURCE RE ULA NS. 180
Si c f pp can✓CanwcRe-roofs m' Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupent atom or handle Ovations;material
u deffrmd by the Cupertino Municipal Code.Chapter 9.11.and Me Health and Safety
and,Seetian zss7z(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ✓may^u
Win the appikut or forum building mmp,nl am egdpmenl err dcwiee,which
If a roof is installed without first obtaining an inspection,I agree to remove
itic".tl us sir conuminmu u dc0ned by the Bay Area Air Quality Management all new materials for inspection.
toles) —t
❑Yca /.L7Nu '
I he.read the hosadout materials requirements underChmaer 6.95 or the Canfor.
nia Health d SafclyCode,Sommo 15505.35533 and 75534.1 undeBund thollNo building
does not currently ham a mount the[It k my responsibility he notify the mmmoL of the
mquirepsenuwin v emelpkaa ancanireamara"yP,ncy/8/ Signature of Applicant Date
Ow r13ar/rwM.d,.edagent tom — All roof coverings to be Class"B"or better
r�
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
i
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.........................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). /
—19
Property Owner's Sign aturel�1 � D� b linj Job Address: 62-%r`�°1� C � ��^ r" S Permit#c~ ;�, ( ch , `1501An chan es to the info ation rovided on this forms all be submitted to the Ci of
Department.
r
CITY OF CUPERTINO
WATER HEATER
eCUPEII;TINO PERMIT APPLICATION FORM
Date:
APN# J v S� 03
Building Address:
st
Owner'sName: Phone#:
2 o uv '1U - 7LIZ - I O
Contractor: /% 1 honey License#:
Contact: / Y V Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Des ription:
Residential Commercial ❑
Cost of Project: J
Strapped n Platform Bonded
New Location ElReplacement ❑
Qty
AppVc,41le Fee ]D Fee Description Fee Group
BPWHEATER Water Heat /Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
Z22J I
60. G �