05040142 CITY OF CUPERTINO �
BUILDING utvlslory PERMITCI
ONTRACTQR NFORMATION
Rte LDING ADDRESS: HOT WATER INCH FEKMIT NO. 5040142
-191 rr)TT�MBTj_q A.17
OWNER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY O. CONTROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONIRACIOWSDECLARATION JbDsi [ion
u I Mindy affirm Thal I am licensed under provisions M oDescription
Chapter 9(commencing
with Section 70M) f Division 3 of the Business and Professions Code,and my license is
j = in fall fame ire erfcel 36 4� �— REPLACE WATER HEATER
License CI Lie.N _ -
u1- Date Camm�or -_
QQ ARCI{ITECI'S
Et
XTI
1 understand my plans shall M used as public accords
ziyU
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Licensed Professional
OWNER-BUILDER DECLARATION
1 Marty affirm that I am exempt from she Contractors License Law(.,,be
�po following reason.(Section 11131.5,Businessand Professions Code:Any city or county
X S� which requires a permit it,construct,eller,improve,demolish,or repair any structure
at a^ prior b)its issuance,also requires the applicant for such Permit o file a signed statement
that M is licensed pureuam to the provisions of the Comecmr's License Law(Chapter 9 Sq. Ft. Floor Area Valuatio
fi
rc�el (commencing with Section 7")of Division 3 of tM Business and Professions Code)or
y Nat M is exempt therefrom and the basis for the alleged exemption.Any vwhala of
Section 1031.5 by any applicant for permit subjects the applicant o a civil penalty of 3ASbT4,1j*Aer00 Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the propeny,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered(orale(See.7(44.Business
and Professions Code:The Contractor's License Law dors not apply to an owner of Required Inspections
property who builds or improve deaon,md who doeauch work himself orthrough his
employees,provided Um such imptua<ments are not intended mattered for ale.If.
however,the building or improvement Is sold within one year of completion,rhe owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1.as he,of the impray,am exclusively contraeling with licensed contractors to
cuostrucuhe project(Sec.7(N,L Business and Profccsians Cade:)TM Convector's U,
room
❑ Lnor apply man Owner orproperty who or improves themamI(ahal-7::
who
tactsfor
such projects wiNacomnnor(s)licensedpursuntnto the Contractor',
License
Lis-
1 aanempt under Sec. B&P C far his cuan
Owner Dasa ED WORKER'S COMPENSATION DECLARATIONrI hereby affirm under peoaltyof perjury aro of the following declanda.: L---� ✓ sU JUI haveand will maintain aCeniOueate o(Cooseno self-iaum for Workeri Cooper-
la3l."�'Xl
nn,as provided for by Section 3100 of the ISMr Code.for the performance of the
rk for hicktrupermitisissucd.
rvc end will maintain Worker's Compensation Insurance,m mquimd by Serino
of the"Mr Carle.far the priformance of the work for which this permit is issued.
Workers_Com/pensation I/n^s onceJ.micr and Policy numM'r/artier: -/7t:f/, Y//I�/A Policy No.:��T`��'a�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not M completed If the permit is foram hundred dollan(SIM)
or loss.)
1 certify that in the performance of the work for which this Permit is issued,I shall had
employ anypromen in any mothertu�ccome sulRnmthe Wohcri ComMosniim
Laws of Coliform" r(M �
APplicam 66� V
NOTICETO AP)'GLA r f,after making this CentOcem o ase , u should
become mhjat to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with each provisions or this permit shall k deemed mvakcd.
E[-.Z i CONSTRUCTION LENDING AGENCY
1 hcmhy affirmat th
them its comtruction lending agcay far tM perfurmence of
((.7 thc work ser which this Permit is issued(Sec.3(191.civ.C.)
(i7 0 Isnders Name
z Le der';Address
f)Q 1 certify thal I have read this application and sate that the shove Information is
F career.1 agree to comply with all city and county ordinances and state laws reining to
0U building Construction.and hereby authorize representatives u(shis city to enter upon the
x[51 alcove-mentioned property for inspection purposes.
(•+1 (We)agree to arc,indemnify and kap hamnless the City of Caperton against
rq liabilitierjudgments,costs and carcass;which may in any way seems against aid City
U in consequence or the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplicaDran,IIA2ARDOUS MATE RIALS DISCLOSURE Type of Roof
Will the applicant or future building uccupam Hort or handle haasdous maaritl
as dcOned by IM Cupertino Municipal
Cao,Chapter 9.12,and the Health and Safely
oJc,Section 25532,7)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Ye. a P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
sh hamodous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
7ducs
stfir?
El Yea 914
Ihave mad the Weandrws materials requirements under Chapter 6.95 of the Califor-
a Heal"Safety Calc,Sadtms 25505.25531 and 25534,1 undersand that if the Wilding
�not currcmly have a tenant,dot h is my res sthJiry m nwily tM cecupat nl the UUU�I�i�fi1777�ii���goimmen hien stMmet riml�aanyq� cenireateoracapaney. Signature of Applicant Date
'r"" - All roof coverings to be Class"B"or better
Owner r amhmiad agsvt— Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
UPERTINO
Building De artment
JOB A51 ESS: PERMIT # OSO
OWNER'S NAME: h jo oma WI PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
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 71C V ti G ,� / -3-//
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO J S
2-1
WATER HEATER
-- CUPERTINO PERMIT APPLICATION FORM
APN# 3i 01L — l /_ v b/ Date: 1/Z5
Building Address:
Owner's Name: Phone#
6 d
Contractor: Phone: License#:
HOT WATER, INC. �3`�y� –76qAq INA
Contact: SAN CARLOS, CALIFORNIA 94070 Phone: Cupertino Bne License#:
rr 5 Czi s
Building Permit Info:
Bld . ❑ Elect- ❑ _ __ _ Plumb t!�' _ Mech ❑
Job Description: /
Residential Commercial ❑
Cost of Project:
Strapped ❑ On Platform ❑ Bonded:F-1'-' `r : ,
New Location ElReplacement f 1/
Applicable Fee ID Fee Description: Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
(7-