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CITY OF CUPERTINOsew"+
CON�TRAGTORINFORMATIQNm
BUILDING DIVISION PERMIT
Bu1LDINC ADDRESS:
CART RI RT
HOT WATER INC
PF1"N0502004I
•2-2224 -A -ANCA
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
(650)298-8494
ARCHIIECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I Nn I am li¢mm under provisions M Chapter 9 (commencing
p
ion 7 Oaffirm).fl
with section 101111) or Division 3 or Nc Budra:ss am Aofcsduv Code.and my liccmc is
in full 3ndeffect. a ��
REPLACE WATER HEATER
Da¢�Contra
CfA
/ ARCHITECT'S DECLs t TION
I understand my plans alull he used as public meords
Licensed Proressional
OWNER -BUILDER DECLARATION
I hereby Jr.4Nat I am exempt from the Cmur acme, License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which mquires a Permit to comuruct, alter, impmw, demolish, or repair any structure
prior it) its Issuance. also rcytims the applicant for such Permit to rile a signed statement
that W is licensed pursuam to Ne provisions of the Contruori license Uw(Chapter 9
Sq. FC Floor Area Valuation
(commencing with section 7") of Division 3 of the Business and Proressions Cmc) or
that he is exempt ftmfmm and she basis for One alleged csemption. Any violation of
Sccdon 1031.5 by any applicant for a Permit ubjects the applicant to a civil penalty of
3 24a31,IINul&er0 0
Occupancy Type
P Y YP
not more Nan five hundred dollars (5500).
1, u owrmr of the property, or my cmploycu with wegu u their sole cornpcncotlon,
will do dm work. and Ne structure is not Intended or Offered for sale (Sea. 1(A4, Business
Required Inspections
and Profession Code: The Contractor's LI¢nac Law does not appy in an owner of
pmpeny who builds or improves dieroon, and who docs such work himself err through his
own employees, provided Not such improwmenu are nal intended oroncred for sale. If.
however, Ne building or impmvement is sold within one year of completion. the owner.
builder will haw the burden of proving char he did not Wild or improve for purpose of
( /'>
/-
sale.).
t .
❑ 1, as owner of the propert, am uelusively contracting with licensed mnuaebra to
constmct the es not an U.in Business and professions ds or c pee Conuacmis Li-
cove Law dos not apply to an owner of proper( who Wilds or imprnw thereon, and f
apply
�, .z„
whence Laces for such pmjccu with acontrutor(s)Iicenud pursuant to Ne Canuactots
License law.
Ej I nen exempt under sec. . B & P C for this msson
Owner Dau
�F,JG
U ti
f
WORKER'S COMPENSATION DECLARATION
GGGIII // D.
1 hereby affirm under penalty, of perjury one of the following declamations:\
1 haw and will maintain a Ci nifc+¢ ofCmeent to self buUm for WOfte$ CompnF
action, u provided for by Section 31011 of the labor Code, for the performance of the
h for which this permit is issued.
i
®diose and will mnintdn Worker's Cpmpevation I... as minted by Sccdon
37W of dm Labor Cade, fcr Ne performancr of ft work for which Nis permit is issued.
My Wmkci``s C�ampevation Inunnce cam,, and Policy num: p /
Carrier. o7dte��Z r rU PLA Poliry No.: Jber arty er "7a b
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fndssecfion rem nut W completed if the p .I, Is mronc hundred dollars (SIM)
or lcaa)
1 cenifv Nat in the performance of de. work for which this permit is issued, l shall not
employ any person in any manner so as in become subject to dee Workeri Conformation
Laws nrcdifomis Da¢
Applicant
NOTICE TO APPLICANT: IL after making Nis Cenifeau of Exemption, you should
became subject to chc Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such prvisious or this Permit shall W deemed mwked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat (hare is a construction lending agency for the Performance or
Nc work for which his permit is issued (Sec. 3M. Civ, C.)
Lender's Name
Lender's Add.
I certify that 1 have read this application and state that the above information is
Correct. I agree in comply with all city and county ordinances and state laws relating to
building construction. and hereby amharim reprmenmiws of this city to cater upon the
J
/
ahovc ia profor ipeclion purposes.
(Wn) agrpr per( m
(We) ee to cove, indemnify and keep hart an the City ofagainst
5
in ,.,. t
osteouswhich toryin any way accrve againslaaid City
O.,.,.at
lieconsequenceo
in of thegrataintl
this Permit.
APPLICANT UNDERSTANDS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE ftEGtILATIONs,
Re -roofs Z '
Type of Roof
Signamrt or ApplicanuCantractorRDOU Date
HAZARDOUS MATERIALDISCLOSURE
Will she applicant or future building occupant
nt stem or handle hvallous material
as dcGned by No Cupertino Municipal Code, Chapter 9.13, and the HcaIN and Safely
ode. S❑tiYaena 255320411 ply
All roofs shall be inspected prior to any roofing material being
If a roof is installed without first obtaining an inspection, I agree to remove
Will Nc applicant or future Wilding =open, tau cyuipmem err devim which
g
mit hazardous air contaminanu as dofined by the Bay Arta Air Quility Management
all new materials for inspection.
DisuicO /
❑Ycs [fir
1 haus read OR hvardeds macriab myuiremcnte under Cluptcr 6.95 artW Califor.
d. BOOM& SxletyCode. Seetiov 35505.25533 and 25534.1 undersand dedif the Wilding
does rot currently hase_a tenant, Nat it' y maNnability to hadly dee occupant of the
mquirt nmmc yhichrt(ush ,L fur iIIUNCCpfaCcrhfcaleOfa
reofApplicant Date
All roof coverings to be Class "B" or better
Owner T�
or aumonved agent
CITY OF
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building De artment
JOB ADDRESS:
as,33 ,/
PERMIT #
0, 6-C o
OWNER'S NAME: —oh n 91 -an -e—
PHONE #
GENERAL CONTRACTOR: li O r /ti c-
FAX #
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
Date
Owner/ Contractor Signature
1Y/19s-
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
gJafir Ii G
o2
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
1Y/19s-
Date
1�
•
518M
CITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
APN # 3
�(
Date:
Building Address:
o? a) 33 `/ rjl7ti �� a c ct �f
PPERMITFEE
Owner's Name:
.J oA rnOr" i'l—¢.-
Phone #:
1fo$- at/S - a, y9
Contractor: Phone:
License #:
Contact:. Phone:
Cupertino Business License #:
C;h�ls 6u� /C(M �PSo-(a3
a/
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 9--'
Mech ❑
Job Description: 1
d ' ��1� l71 rG
Residential Commercial ❑
fD
Cost of Project: SSU
Strapped ❑ On Platform ❑ Bonded ❑
❑
New Location Replacement
Qty. if
ADDlicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
( BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING