05020153 CITY OF CUPERTINO
BUILDING DIVISION PERMITsCONTRACTOR INF'.ORMATI ON X
BUILDENGADDRMS: HOT WATER INC Ps" 'T"65020153
OWNER'S NAME: PERMrf ISSUE DATE
DARWIN
ONE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y 00 hat I amCONTRACTOR
order S DECLARATION Job Description
Z 1 hereby affirm that I am 3.f the
Bd under previsions of,Capmf 9(commencing p
n< wish Section 7IX10)mf DiviaimnJof the Business and Pmfmsions Cada.and myliccnu is
_eahinfu0fumeandeffecL C3 ua.a b�(o/� REPLACE WATER HEATER
fur i Licenx Class
?—O Dam Confrarmr a.L
'y ARCHITECTS DECLARATION
<< < 1 understand my plans shall be used as public records
JyU
G Licensed Protract onal
OWNER-BUILDER DECLARATION
<I 1 hereby affirm Nm I oen exempt from dm Comraaor's License Law for the
—
00 following mason.(Section 7031.5.Business and Prefessiom Cade:Any city or county
m� which require a permit to consumer.ifl e.improve,demolish,m term,any a.ctart
prior m its issuance,also require the applicant for Inch permit to file a signed statement
Hoar he is licensed pursuant to the provisions of Ote Contractor's Licenx Law(Chapter 9 Sq. Ft. Floor Area Valuation
,fin (commencing with Section 7000)of Division 3 of the Business and Professions Corte)or
— Ne u at hexempt therefrom and dm baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2y0810)Mft10 0 Occupancy Type
not mom Nan five hundred dollars(5500).
0 1,az owner of the properry,or my employees with wage as their Into compensation, Rao R fa
will do the work.and lheswmum is not intended or offend for safe(Sen.704,4,Businessn m: lis al
and Predicated..Code:Toe Comment's Lt..Law dao nal apply mj
an owner of �RcuiredIInspection-s�
propeny who Wildsorimpraves thereon,and who doessuch work himselfar damage his
own employees,provided than such improvements are not intended oroRemd for sale.If.
however,Use building or imprevemcnr is sold within one year of completion,the owner-
builder will have the burden of pmving that he did not Wild or improve fm purpose of
sale.) 2005
❑1,as owner of the SeeproaPerty704.m views andvely confessions with:) Ccntr c fur's m �S p s.��yp j
tuns,,La the cover
not (Sec.n an Business and Professions Wilds
Codc:)"BeThe vet t1b mon, Lid flu
N y (I .y'�
c lowdocsnmapplyjeoownerofpropcny whooeadaorimprove Conan& Iliie:!!!utly� a'1'_
whocve Law for such projccu with aeanrsefm,(s)liunxd pursuantmdte Convaefoli y� A
Licenx Law.
❑1 em exempt undo,Sec. .B&P C for this rtazon
Owner Data
WORKER'S COMPENSATION DECLARATION -
40 I hereby affirm under penalty of Perjury one of the following declarations:
I have and will maintain a Cutifiate of Conserv to self-imum for Workers Camper.
cation,as provided for by Section 3700 of the Labor Code,Int the Performance of the
workforwhich this permit is issued.
&I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the"hot Code,for do performance of the work for which this permit is issued.
My Wafte,Compensation Inxrince aria and Policy number arty:
Cmric, FU it A Policy No.:/S k/p 3B /o
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectitm need not beeomplcted if the permit is fim one hundred dollars($1011)
or less.)
I sonify Bar in the perfamunce of the work fm which this permit is bused,1 shell of
employ any person in any mannerso az w became subject to the Workeri Compemation
Laws of Califamia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
eccomc object in the Wooer's Compensation provision of the Lahr Code,you most
.J O forthwith comply with such provisions or this permit shall W deemed m.oked.
'Z'-" CONSTRUCTION LENDING AGENCY
[-+ "�" I hereby alarm that them its comuucHinn lending agency for the perfmmoce of
C' the work for which Nis permit is issued(Sec.3097,Civ.C.)
W� Q Lendeh Name
Lent iAddress
U O 1 cattily that 1 have mad this application and sate Nal the above information Is
U. corms 1 agree to comply with all city and county ominances and state laws relating in .
0 U building ca.,hin,and hereby•uthmrim termscnutisesof Nis city to row,upnn the
above-mentioned progeny for important purposes.
F y
(we)osteo to save,imicronifyexpen and keep harmless the City of Cupertino aid City
N lia.mostap...ethecosuand expemm which may in any way accrue against said City
Uz AePLICANce of the RSTA sof this per mit t
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �L 7
SOURCE REGULATIONS.,, n ,,
�' h o YG (ate^ �1a3If� Re-roofs
Signamm of ApPlicamucim a xor Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hamrdous material
jjjkdefined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
ode,Section 25532(1)? All roofs shall be inspected prior to any roofing material being installed.
See
f
Will Bic applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by plc Bay Area Air Quality Moagomcnt all new materials for inspection.
D
istrict' �
❑Yes ET1N
I have mail the hurardouamacrials requirements under Chapter 6.95 ofthc Califor-
nia ) 5
Health&Safety Code,Smuam 25505,25533 and 25534.1 underimeW Nstifdr building
not eurood,have a tenn,Nm it itis my raspy mibihry m madly the aeupam of thequirementswhichmustocmnp'orwissuanccofaCcrtifcafc raamfry. Signature of Applicant Dale
1,,A� :a y aZ;_24
Owner or authorind agent Dam All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
? -Z4, Cupertino CA 95014
Telephone(408) 777-3228
CITY 0,� Fax(408)777-3333 UPEkTINO
Building De artment
JOB ADDRES PERMIT #
1001 fin e - Lot 260 O Soa O /53
OWNER'S NAME: 00 lrW I Gt, Ma v PHONE # 51
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin' 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 4-
lq/ r✓ 02
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�ih/ti c a 23 oS
Owner/Contractor Signature Date
�F CITY OF CUPERTINO
� S
Can WATER HEATER b S
CUPERTINO PERMIT APPLICATION FORM
APN # 3.2— (�2 _ �� Date:
49c�" DS
Building Addres
/ k17 E fie
Owner's Name:. Phone #:
trw( N YYlCc `l 08 —7 7 55:
Copttor: /ems � Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb LJ Mech. .❑
Job Description:
�v�e Jr✓ev /� !r S cL r�577cZ(v��3
Residential Commercial ❑ T� p ��f2✓i or
Cost of Project: 5QU
Strapped ❑ On Platform_❑ Bonded ❑ - - ---New Location ❑ Replacement L�
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.