04010063CITY OF CUPEWHNO
BUILDING DIVISION PERMIT
gxC®NTRACTR�NFO MAT,70N.
BUILDING ADDRESS:
HOT WATER INC
PERMIT Not) 4010063
OWNER'S NAME:
PERMIT ISSUE DATE
D
ONE:
-
SANITARY NO, CONTROL NO.
(650)298-8494
ARCHITECT/ENGINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0 0 0
LICENSED CONIRACTOR's DECLARATION
Job Description
I hereby affirm Nn I em licensed under pmvisions of Chapmr Y (commencing
p
with Scnion 7(N9)of Diviaion]of NC Busima and Pra(.u' m dp. and my license is
in full forte and cffettG3_-/2
License 1..� .a LIc. R
WATER HEATER REPLACEMENT
Dale canlmcmr
fes"="���9-y"�_
A CHITECTS DECLARATION
I un0 stand my plain shell he used as public records
..
Licensed Protean ... I
OWNER -BUILDER DECLARATION
I hereby of on that 1 am exempt from the Commelors License Law for the
'
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which uyuires a Permit to colWrutt alter, improve, demolish, or repair any structure
,He, to its issuance. els. requires the applicant Carmen permitt. Me a signed...wro m
that he is licensed pursuant a the previsions of the Contractor's License Law (Chapter 9
Sq. FL Floor Area
Valuation -
(commencing with Section 7000) of Division J of the Business and Professions Cadc) or
that he is exempt Oemfmnt and the hue for the alleged exemption. Any violation of
int...
3 2,6`518021ftro 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects On applicant o a civil Penalty of
not more than Eve hundred dollars (5500).
-N C
01. as owner of the property, Or my employees with wages u their sole compensation,
r !✓
will do the wmkand theswaum isnot intended oroRered fo... I.(Sec. 70,14, Business
and Professions Code: The CemmuctorY Lim. law data nal appy m m owmr of
/(` eq it d Inspections
pmpeny who builds or improves thereon, end who does such work himself or though his
\�.
.we employees, provided that such improvements us not Intended mattered forsale. If,
however, the building or improvement is sold within am year of completion, the ownet-
builder will have the burden of proving Nal he did not build or improve for purpose of
sal..).
❑ L as owner of Ne property, am exclusively contracting with licensed cammctors to
'_1
construct the pmjea (Sec. 7(314, Business and Profusions Code) Time Commor's Li.
come law does not pply to an owner or property who build. or improves themon, and
who contracts for such projects with o comracwr(s) licensed pursuant to the Contractor's
Lim. law.
'
❑ 1 sm exempt under Sec. . B & P C for this ¢axon
owmr Data
WORKER'S COMPENSATION DECLARATION
1 hereby eMe. under penally of perjury ore of the following declavlians:
I have and will tralnedn a Certificate or Cement to self -insure fm Wa kei a Compen-
sation, as provided for by Smion 37M of the Labor Code. far the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation W xomm, as required by Section
.
37W of the labor Code. far Ne performance of the work for which this Permit Is issued.
My Worker's Cam xtiom Insurance carrier and Policy num rase:
Carrier. t/M 0 Policy No.:
CE IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mdasectionmcdnathecompletedifihe permitisfmomhundmddellsor SIM)
Is...)
I unify Nat In the performance of the work fm which this Permit is issued. I shell not
employ any person in any manner so as to become subject m the Warker3 Compcdeatlon
-
law. of California. Data
Applicant
NOTICE TO APPLICANT: If, after making his Certificate of Exemption, yin should
become subject 10 the Wmems Comp.nsalion Provisions of the Lahr Coda, you must
forthwith comply with such provisions or this Farm it shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a comtmction lending agency Our the performance of
that work for which this permit Is issued (Sec. 3197, Civ. C.)
Under', Name
Lender's Addrcas
1 certify that 1 have read this application and sum that the above Information is
aorect. I agree to comply with all city and county ooli. and state laws alsting m
Indicting convection, and hereby authmne rcprcsmotives of this city to enter upon the
.howmcnlioned pac ty for Impcnion purposes
(We) agree Us save, indemnify and keep harmless Ne City of Carper ino against
IiabiliOes,Judgmenes, costs and expenses which may in any way ¢clue against said City
in consequence of Ne granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date ,
SOURCE R�iyL'AT S.
Re -roofs
Type of Roof
/� /Z � Q//y 0L/
signawrc or pp caHAZA m� for r 1'P¢
HAZARDOUS MATERIALS DISCLOSURE
WIII die applicant sfuture Wilding occupantstore or handle amaurid
defined by Ilrc Cupertino Municipal Code, CluPur 9.12. and the HaIN and safety
Health
CC
cad.,Section :ssJa(a)7
All roofs shall be inspected to any roofing material being installed.
Yes QNm
prior
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant of future building occupant etc equipment or d.vicee which
It W ardous air conumimmus as defined by the Bay Arts Air Quality Man ,meoll
all new materials for inspection.
WrieO
C) Yes in No
Ihave afet the hanarthmss25505,requirements under Chapter6.95that Califon
ria HralNg: Safety Code,Secuans ]SN)5.255JJ and 25534.1 understand the if the luilding
if On
dins not cunently how a moan, Nat It is my responsibility m nod l'y the a<uPant of Ne
requiromenuwwjuAsWisl ma urwism;ce.r.cerurttmmofOc .Q
Gam
$IgnAfllr of Applicant Da[
All roof coverings to be Class "B" or better
owner
orautho ed seen]
C
ciTr o
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
APN # 3 2, / O 2-0
Water Heater / Vent
Date: l '
Building Add ss:
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
Owner's Name:
Business License
P one #:
I
9/00 1 u
Contractor: Rhone:
License #:
Contact: -
C
e:
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑
Plumb
Mech ❑
Job Description:
�—✓ % ilC f 1 J3 �$,�,
�2%�/J�vrAC.�r,•�.vf
Residential Commercial
❑
Cost of Project: (4%Tz
Strapped El On Platform 0 Bonded El
❑ 457
New Location Replacementt
Qt f
An6liCable Fee ID
Fee Dn.,rrintinn
Fee C7rnnn
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
v� 2-