04030185 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;CONTI2AI�QRg r.I, 3NOMATOPI„ ,
BUILDING ADDRESS: PERMIT NO.
HOT WATER INC 04030185 '
OWNER'S NAME: PERMITISSUBDATB
ONE:DICK KI.E.14T. 9531 GRACRI-P.—NP AVE SANITARY Ap 7'24�2@9&OLNO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p l=
a10 Z0 LICENSED CONTRACTOR'S DECLARATION Job DOSCrIpt10D
I 1 homey apbon that I am licensed under provisions Of Chapter 9(commencing
with Section 70(X1 of Dlviaion 3 ofthe Business;and Prefsaaiom Code,aod my license u
flnfell rmwlmdcff REPLACE WATER HEATER
5 Z License Lie.N
z11I--- Dam Contramr
nilAR HITECTS DECI-ARA O N
tau 1 undemand my Plans shall be used u public records
Licensed Pmfcuianal
OWNER-BUILDER DECLARATION
nI ri hereby. .(Soe that 11. eumpt from the ConuaWrd :A License taw for ly
i be
O ee following moon.(S nit t III3 L4 Bosless and Re,de ons Code:Any tiny nr fumy
u,$o which its irce con•pc asse maim theenter.Improve,dcermittmrepair anytatucmm
F te ti prior its iuua d parr m r 1.da,the applicant fomuch permit to ncrle esigatl statement
F dus,he(commslicemodpuntion7 )Of DivisionoftheBuecmr'aUttnmlars,Codtm9 Sq.Ft.Floor Area Valuatio
y,Sp$
(commencing with Section and
of basisofrnflMeged euand
on.AnynnsCode)m
a.• Net he b eumpn IMrtOom and Ne Eu6 for the alleged exemption.Any vloleuon of
Section 7031.5 by any applicant for a permit subjects dte applicant W a civil penalty of 3 2W.W4,W*gr0 0 Occupancy Type
nut more Who Bw hundred dollars($500).
❑I,uownerofthapmpmy,mmyemployeswlthwag""Weirmlecompenadon.
will do thework.Ard the structure is not lnumdulmoffemd fnrale(Sec.7044.1uJmu ` uired Inspections
and Prom.Wom Cads:The Clumem oM1 License Law don not apply W an owner of r fel, P
property who bullNmimprowa deerson,and whndceaaeh work himselfertiuough bis
awn employe",provided thauuch improtsmenu am not intended muttered for sake.If. t ^t
however,We building or improvement is sold within ane year of compledon,We owned u J
builder will have the burden of pmving that he did at build or Improve for Purpose of + t
oke,). r, I
❑I,"Owner of the property,am"elusively contracting with Ilmmed eonuse ms m
construct the pro)ect(See.7044.Business and Professors Code:)The Conusemr's U-
cense law does not apply W an owner of property who Wilds or improves thereon.and, 7
who contracts for such projects with a conuaemr(s)licensed pursuant to he Conuamots /
License Law.
❑1 am eumpl under Sec ,B k P C fonhis moon
Owmr Date
WORKER'S COMPENSATION DECLARATION
1 hereby effort under penalty of patJury one of the following declarations:
I have aha will mainWn•Certifies.of Consent W self-insurt for WadechCompa-
ution.as provided for by Sold..3700 of the labra Code,for the perfoonence of the
work for which Wi permit la issued.
t�L,l have and will maintain Wmtrfs Compensation 1"urenm.u required by Suction
`5760 of the Inbar Code,for the performance of de,wart for which this permit Is issued.
My Worker Comppmeadon Insurance cartketand Polleynu bar see:
Cartier: [AT; 'few Yes Policy No.: LI
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(this section need not be completed lithe porth Is forme hundred dollars(SIM)
or leaf.)
I certify that in the performance of an work for which this permit is issued.I shall not
employ any person In any manner an Is,W become subject to the Workers CamPemadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CcniO"m of Exemption,you should
become Subject W the Worker.Compensation provialona of We labnr Code,you most
QZ, forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
F. 1 hereby affirm dui Wem Is a construction lending agency fest the perfufmmce of
C> the wurk for which this permit It issued(Sec.3097.Clv,C.)
W Q lenders Name
CL, z Lenders Addle..
V Q I certify that I hew lead this application and sum that the show informniun is
U, correct.I agree to comply with all city and county ordinances and fate laws relating to
Q building comrucfion,and hereby aathmim leplesenutivm of thin city W enter upon the
W shove-memionod property far W peetim Purposes
(Ws)agree to ave,indemnify and kap harmlm the City of Cupertino Against
rrA liabilities,judgments,costs and expenses which may In my way accrue against said City
U In comegmnce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE REGU N
il�e-(4 63 zK/Cy Re-roofs
Signature ofA icanVConuadtior t Else,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle haundous mammal
Is defined by the Cupertino Municipal Cade.Chapter 9,12,and the Health ad Safety
Code.Section 15531(47 All roofs shall be inspected prior to any roofing material being installed.
[:3 yes ON.
Will the applicant or Cloth,building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hnralloua air contaminants u ndcfncd by the Bay Arta Air Quality Management all new materials for inspection.
Dril A7
❑Yea 0 N
I have maxi the heom ous materials requirements under Chapter 695 of the Cxlifar
ria Health h Safety Code,Sections 75505.25533 and 25534.1 understood that ifthc Wilding
docs not cuoendy haw a Wrenn cost It u '
my responsibility to nod] the occupant Of Thu
requirementsbemet priormiuvance a fa Certificate of Occypancy. Signature OfAPP heart Dale
TIC CP �7/_L Oy g
All roof coverings to be Class "B"or better
Owner orauthoHndagent �,�
Community Development
10300 Tone Avenue
� ' ,� Cupertino CA 95014
Telephone(408)777-3228
Cl OF Fax(408)777-3333
SUPER,TINO
Building De artment
JOB ADDRESS: PERMIT#
2CA(�o 6 2 C f6,*s7-,)E- dol .
OWNER'S NAME: ( i S USGr3i PHONE
GENERAL CONTRACTOR FAX # < S'd G y�;
I am not using any subcontractors: 0315ello t-
Signature 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 1i✓c wC.
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# _S 9 O Date:
Building Address: lD
j0 512_
Owner's Name: Phone #:
a I h o 9i - Y2Z
Contractor: Phone: License#:
. HOT WATFR INC 050 -Z3(a16;1—
Contact: SAN INDUSTRIA
ALR OAD 9NIT D Phone: Cupertino Business License#:
a
Building Permit Into: —
Bldg
nfo:Bld ❑ Elect ❑ Plumb 0�rl Mech ❑
Job Description: Zk-VJam_ rWU❑T�1 _
Residential Commercial
Cost of Project: ,500 Oj
Strapped ❑ On Platform ❑ Bonded
New Location ❑ Replacement
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