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BUILDING DIVISION PERMIT
GONTRAGTOR TNFORMATION
BUILOINOADDRESS:
HOT WATER INC
PERMITND03090022
'ER'S NAME:
BLOCK GORDON
2531 GRACELAND AVE
PEnMre ISSUE DATE
a
PHONE:
(650) 298-8494
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
1 hereby affirm Nat I am licenced under Provisions of Chapter 9 (commencing
With Smile. 90(X1)of Division Jof On B ainessuud Professions Code.and my human is
u«i'sc°m;4"d /
WATER HEATER
Lk.g
DamContractor
CHITECT'S DECLARATION
1 understand my plans dull he used As public race,&
LimmcO Pwfinamnel
OWNER -BUILDER DECLARATION
1 hereby affirm Out 1 am exempt frum the Contractors License Law for the
following nausea. (Secdon 7031.5, Business and Professions Cade: Any city or county
which wyuires . permit to construct, alm6 improve, demolish. m repair any structure
prior N its issuance, also Acquires the applicant for such permit to file a signed summons
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions or Be Common'sLiecasc Law (Chapter 9
(commencing with Section 7") of Division J of He Business and Profession Code) of
r3-5604041.00
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
pp ;Number - ..
Occupancy Type
Section 9071.5 by any applicant for a permit subjects the applicant to a civil penally Of
not more than five hundred dollen ($500).
1_ 1
p. y, y ponces with
I,uowner of Nem n mm em I gas P<
uale(wk cons nation,
r-_� �%
ti ` i
I T w
thea
will do thewons Cand th The Con isnot s tended License offered for nt apply to a.. ince, of
and Code: The Co License Law does not apply to .n owner
themm'&
eny who is
Ownertywhobuildsmimpromslhimprondwho Are not in work oroffeedNwugh his
mmwuvenet for ssk. V•
accent
50�6f�[, Gga Es-
' GING
howemploym,pang or improvement I. year of completion.
builder, Nebuildingboimprovementissoldwithinone year of completion, the owner-
�.1
builder will Nm the burden of proving Nat be did not build or improve for purpose of
(•�A'ANAL`f
/� 7
(i'gl/
❑ 1, as owner of the property, am exclusively contracting with licensed conuacwra to
til
consumer the project (See. 7044, Business and Professions Code:)The Contractors Li.
mass law does not pply to an owner of property who builds or improves Hereon, and ,
who contacts for such pmjecu with a contractor(s) licensed pursuant o the Contractors
License Law.
❑I em exempt under Sec. ,8&PC for this mown
Data
WORKER'S COMPENSATION DECLARATION
1 hereby am. under penury of perjury one of the following declam imu:
❑ I ham and will maintain a Cmllimm of Consent to self -insure for Worker'aCompen-
sation, u provided for by Section 37M of the labor Code, for He performance of the
work for which this permit is issued.
have and will maintain Workers Compensation Insurance, ss required by Section
J 00 of the Mr Code, for the performance of the work for which this permit is Issued.
rt:
My Worker Compewuon Insunnee esrticr end Policy nuM:
Cartier. Policy No.: �
ER IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nmtl nothe completed If the permit is foram hundreddollara (SIBB)
or kss)
1 certify that in the performance of the work for which this permit It issued. I shall not
employ any person in any mwnerw As N become subjmuo the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, .Bar making this CeniOcam of Exemption, you should
become subject to the Workers Compcnsauon provisions of the IeMw Code, you mut
foMwith mmPly with such provisions or His permah shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemhy affirm Out there its construdina lending agency for the performance of
Ne work for which this permit is Issued (Sec. 3097, Civ. C.)
Londer&Name
Lauder. Address
I minify that I ham read this application arW sum that the show information I.
correct. 1 agree to comply with all city and county ordinances and sum laws misting to
building consuoction, and hereby authorise represenmives of this city to enter upon doe
for impecuon
.hove -nu nmwmd prop.ny purposes.
�i
(We) .gree to saw. indemnify sod keep harmless die City of Cupertino against
liabilities ,judgments, com.nd exam. which may in any way accrue against said City
/ 1�
in comegmnce of to granting Of permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGUWMQM.Q Q
Re -roofs
Signature of Applscam Conuacter I, D.
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne applicant or finnan building occupant amen m handle hanrdous mamdd
as donned by the Cupertino Municipal Code, Chapter 9.13, and the Health and Safety
e, Section 355334)7
(Cpl.
All roofs shall be inspected prior to any roofing material being installed.
❑sem
If a roof is installed without first obtaining an inspection, l agree to remove
Will the applicant or future wilding occupant taw equipment at devices which
t haurdous air contaminants u defined by the Bay Arta Air Quality Management
all new materials for inspection.
1,I.ricR❑Yes
row.
1 ham mail Ne hv4,tes materials requirements under Chapter 6.95 of We CaliforyHca"Safety
Code, Smuons 25305.25533 sod 35534. l unummund Nan ifHe Wilding
not currently hew a tenant that it is my nesponsihility to notify the occupant of the
naquinamcma whj,�mA'b pnorl 'ssuancc ofe Cc,ficamofu cu
Signature of Applicant Date
0
All roof coverings to be Class "B" or better
Owner tar awh9m.dagont ate
r�
It2Tn 5 of 8
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35604041.00
DATE ISSUED.......: 09/03/2003
RECEIPT #.........: 23003
REFERENCE ID # ...: 03090022
SITE ADDRESS .....: 10665 CLUBHOUSE LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: euem
COPY # : 1
OWNER ............: BLOCK GORDON
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3907
RECEIVED FROM ....: HOT WATER INC
CONTRACTOR .......: GUSLANI, CHRIS LIC # 21311
COMPANY...........: HOT WATER INC
ADDRESS ..........: 2531 GRACELAND AVE
CITY/STATE/ZIP ...: SAN CARLOS, CA 94070
•
TELEPHONE ........:
(650)298-8494
FEE ID
UNIT QUANTITY
AMOUNT
PD -TO -DT
THIS REC NEW
HAL
---------- ------------- ----------
BENERGY PERMIT FEE
1.00
----------
23.10
----------
0.00
----------
----------
23.10
0.00
BPWHEATER PER
HEATER
1.00
9.99
0.00
9.99
0.00
PPERMITFEE FLAT
RATE
1.00
35.52
0.00
35.52
0.00
TOTAL PERMIT
----------
68.61
----------
0.00
----------
----------
68.61
0.00
VOICE ID
DESCRIPTION
VOICE
ID
DESCRIPTION
502 FINAL
PLUMBING ENERGY
506
GAS
TEST
507 FINAL
PLUMBING
Is
CITY O
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
03G'�OT� a—
APN # 2
Date: O?jb�
Building Address✓:
161665 CGvI ho�s�.
10 PPERMITFEE
Plumbing Permit Issuance
PLUMBING
Owner's Name:
/3/-oc 601 N
Phone
ya) �3Y3'o3� 1
Contractor: Pho
lM� 2? Ig
Licen #:
Contact: s G Lc r�.0 � Ph � S�
,
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: p
rapped ElOn Platform ElBonded Elw
rNe
Location ❑ Replacement R
Qty. if
ApplicAc Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
10 PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING