04030187 I CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR.INFOItMATION
Bu1LDINGADDRESS: HOT WATER INC PMMITNO.04030187
OW NER'S NAME: PERMIT ISSUE DATE
SUN
NE: SANITARY NO, CONTROL NO.
(650) 298-8424
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDGO EO LECT PLUMS MWH O
.�o6 LICENSED CONTRACTOR'S DECLARATION
I Mmby affirm that I m licensed under provision of Chino,9(commcndng Job Description
IN Section 70018 of DIA.ion 3 of the Business mrd PrOfoand.Code.and my license is
withSectionL Z(n/Z _ REPLACE WATER HEATER
S, License Lle.a
Z Dam' Contrxeto taJ
9Y AR HITELTSDECLARATION e
Y T understand my plans atoll be used As public records ..a
D
5 sed Licensed Pmfeui...I ) r
a�
OWNER BUILDER DECLARATION n
I hereby affirm Net I am accept from Ne Camnnah License Law far IM ly(
O D following ream..(Smti.n 71131.3.Business and Professions Code:Any city or county \ �� � I f
s$ which requires a permit m
counteract.alter,Improve.Mmol W,or repair any-mmum,
priorw its issuance.also requires the applicant far such permit to rile a signed suument IfI�
Nn he k licensed pursuant to the previsions of Ne Conuactors License Law(Chapter 9 .S - I rAe r--�� Val ujon
¢�$ (commencing with Section 7000)ol DivsionJ of the BuNneasanh Rafcuions CeM)o -- _
.. Net M is exempt therefrom and the basis for the alleged exemption.My violation of _
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 811 M®!YeI 0 0 Occupancy Type
not more Nan Eve hundred dollars($500).
❑Laabwnerofthe property.ormyemployces with wageses lhatraolecompensation,
and Mthesioand Ne he Condamine,Lt. W oRcred snot apply 70th, weer of Required Inspections
and snyProfessionsh Code:The Comlmemr's License law don not him. lf an nwner of q P
property who buildsart ed dmt.a thereon,and who docsamitwok omutf .ed i m aim his
man employer•Provided pr suchimprovementsart not InmMMaro@rM for owner
bawcva the aetbuilding u improvement s hath within one year of c improve
r the owner.
builder will Nm Na burden of paving that he did not build or improve fur purpose of
sale t.
1,As owner of the property,am excludvely contracting with licensed contractor to
cansuuet the project(Ses•70,14.Business and Profession Cade:)The Contractor's U.
cave Law does not apply to an Owner of property who Wilds m improves Hereon,and,
who contracts forsuch prefects with a conwctor(0 licensed pursuant to Ne Canuaotae.
License law.
ElI mm.accept under Sm .B d PC for thisrwon
OwneDam
WORKERS COMPENSATION DECLARATION
1 Mmby affirm under penury of perjury one of the following declarations:
I have and will maintain ACeNBate of Conseml insel6lnaum for Worme,Compen-
.Allen,u provided for by Section 37W of On labor Cade,for the performance of the
wart for which this permit is issued.
have and will maintain Worker's Compensation Insurance,u required by Section
3 W of the labor Code,for the performance of the work for which this permit u loved. '
My Worker' ompemdonlw nmcarinmd Policynumberfm�:
Cartier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Otis sectio.need ren W completed If the permit is form.hundred Mom($1 W)
Or[am)
I certify that in the performance of the work for which this Permit is issued.i mall not
employ any person in any manneran as to become wbjmt to the Worieri Compensation
Laws of California.Data
Appliamt
NOTICE TO APPLICANT.If,after making this Ccniftcam of Exemption.you should
become subject to Ne Worker's Compensation previsions of the labor Cars,you must
.J0forthwithuch forthwith comply with sprovidnns o Ona Permit fiall W domed revoked.
ti CONSTRUCTION LENDING AGENCY
F+`N" IMreby affirm ft.ft.is a construction lending agency far the performance of
a> the work for which this parent is issued(Sm.3W7,Civ,C.)
0 Leader's Nmc
Z)z lander'.AMmss
V C 1 runty Out I have read this application end Aare that the above information la
U,r'. correct 1 agree to comply with all city and county ordinances and state lawn relating to
C)SV^ Wilding construction,and hereby authorise mprewnutivm of this city m came upon the
W shove-mentioned property for impaction purposes.
fY (We)agree to save.Indemnify and keep harmless the City of Cupertino against
o-„cA liabilities,Judgments,toss and expenses which may In my way acerae against maid City
fJ 7 In conmqucve of the grunting of this Permit.
C" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REWA
/?CA f Re-roofs
ofApplicam/Conumnor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII Ne appllanl ser future Wilding omupanta..or MMI.havardons mamdal
As
defined by the Cupertino Mmamip 1 Code.Chapter 9.12.and the Health And Safety
o
❑Yn de,Section 23572(q? -
No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding,occupant use equipment ser devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvarmus air contaminans As Mfincd by tiro Bay Arca Air Quality Management all new materials for inspection.
VICI?
❑Yea ON.
1 have mad the MvrMus material,requirements undcrCluper 6.95 ofthe Califor.
rale HcslNdr SefctyCMc.Secdans 25505,25533 and 25574.1 undersand"if the Wilding
docs not currently Mwdw
w a mmL It is to tic my responsibility modify aeeupanNe
t of
reymmomns whi�chmusH/act pnartoi..e{,pmm of a a Cetunanl
te ODec PF%crLiJ/3�jJ(J./- Signature of Applicant Dale
All roof coverings to be Class"Bre Of better
Owner orwthorized agent- ` �" Dom
•1
aClOF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEf�TINO
Building De artment
JOB ADDRESS: PERMIT #
1s� 1 C �Lc"Mg UU 0y0_30/ 6
OWNER'S NAME: Ja X11-i 6cJcAA-,---r PHONE 0
GENERAL CONTRACTOR Q"F— 4.iq FAX # SO 3 —
I am not using any subcontractors:
Signature 6ate
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- 13 e w h,C.
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/
Contractor Signature Date
CITY OF CUPERTINO 0 3 ����
WATER HEATER 6
CUPERTINO PERMIT APPLICATION FORM
APN# 3 5(o — I O —O 2- Date:3 lO
Building Address:
215-71 b) I ctm OLf c, ftVie-, .
Owner's Name: • I 5 Y I o o IG1e, Phone#:
til�t
Contractor: Phone: (051 License#:
HOT WATER —8 49 —T (P 3(O f
Contact: ROAD UNIT D Phone: Cupertino Business License#:
SAN MS,, CALIFORNIA 94070
a � 3f I
Building Permit Info: /
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: n 1 Ian U, aFP I n „ er
Residential Commercial E] TTLu+
Cost of Project:
• Strapped Lf On Platform Bonded
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING