05010019CITY OF CUPERTINO ' - -
pi+s R?%s!`•s�..'s �°. `ci��``r`� xa
_ _ _
1
BUILDING DIVISION PERMIT
F
03,0 NTRAgTWINF,OR�MATON--dBUILDING
ADDRESS:
WATER HEATERS ONLY
PERMITN005010019
10084 CONGRESS
NER'S NAME:
PERMIT ISSUE DATE
ELEANOR TURMAN
970 E. MAIN ST. SIJITE 2nn
01/04/2005
-
NE:
SANITARY NO. CONTROL NO. '
Pr
(800)835-5946
ARCHIEC iENGINEER:
-
BUILDING PERMIT INFO
-
BLDG ELECT' PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I IOU Description •'
I thereby affrm Nal 1 em licensed under provisions of Chapter 9 (commencing
p -
man Section TrOlf of Division 3 of doo Business and Paramours Code, and my license, is
in 1411 force andeffeµ 3� --�g�j�)
WATER HEATER REPLACEMENT - : --. -- --_-- - --
LicenseClus C._ Inc X
Dale 3 /.[a at
2S CH R 1
- '
1 unticrsunJ my plans P ¢ lith
.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt foam Ne Contnaofs License Law for the
— - - - -- - -
following mazan. (Section 7131.5, Business and Prourca aos Code: Any city of county
-
which requires a Permit to eonsuvn, alter. impave, demolish. or repair any slaclum,
8 0 Q
prior to is issuance, also acquires the applicant fmrsuch permir t file a signed statement
Contractor's uecmcLaw (Chapter 9
Sq. Ft. Floor Area
- Valuation
that he is licensed parncrttothe provisions nthe
(commencing with section 7") of Division 3 of the Business and Professions Cook) or
that he is exempt tM¢from and Ibe bum for em alleged exemption. Any violation of
Ig - Occupancy Type
Section 7031.5 by any applicant for a Permit subjects do: applicant In a civil Penalty of
nor mart Nan five hundred dollar (35(107.
— -
I, m tons of circ property, m my employee with wage az Ncv sole wmpenam
will do the Werk,end estiaWLIYR Ismitimended afoBCRd fafsale(Sac.7 4C, BaamCL
Required Inspections -....-
and Profticdans Code: The Correctors License Law does at apply to an owner or
_.. ..
proparty who builds or improve Verson, andwho doessuch workhimselfor through his
- - - -'
own employee, provided that such improvements are not intended ororferel formic. It,
-
however. the Wilding or improvementis sob within one ycarofcompleuon. the owner.
Wilder will have the Wticn rof proving that he db not build or improve for purpose of
9 N JAYj� L.aoo� —--------_ ___
JAN .. .
Bale.)..
E] 1. as r of th rty. a d coommurr i-
co L ra tweet of the property. contrasions
exclusively contracting with licensedm,mc
II II /
Business and CoticO The r'a Lin
the ISec. . B
.,
Genu law does not apply to an owner of property who Wilds ar improves Neuron, and
tyt�I/tl - .
® �
who contracts for such projects with a conuactor(s) licensed pursuant to the Contracmr's
('pt'
,
Lice—.Law.
❑ 1 an esempt under Sec. . B Ar P C for this ..an
-
neo Dale
WORKER'SCOMPENSATIONDECLARATION
- -
1 hereby affirm under penalty of perjury arc of the following declare orae.
I have and will maintain aCenifica, of Consent to self -insure for Worker's Camper-
cation. u provided for by Section 3700 of the Latin, Code, far am Perintmance of the
work for which this permit is issued. -
I have and will maintain Worker's Compensation Insurance, as required by Section
TBO of Jur tabor Code.for Ne performance of Ne work for whicM1 Nis permit is issued.
-
MyWorker's Cmpensationlna carrier and Policy number art: of �O,`
Carrier: 5 •-41.-.� Policy No.:ASd-DT -n
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(3 bis section need not W completed ifthe permit is forma, hundred doltar(SIW)
or less.)
1 certify Nat in the performance of the work for which this Permit is issued, I ,droll not
employ any person in any manner so az in become subject o the Workeoi Compeauauon
Laws of California. Dam
_
.. _
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam of E¢mption, you should
become abject to the workers Compensation provisions of are Labor Code, you mum
forthwith comply with such provisions or this Permit mass be deemed revoked.
CONS3RUCcIDN LENDING AGENCY
1 noanion that them is a construction lending agency for the Performance of
' the work four which Nu permit u issued (Sec. J091, Co. C.)
lender's Nauru
lcrbcr's Address
I certify that I have read this application and same Nat the above information is
'
' correct. 1 agree to comply with all city and county ordinances and sum laws misting m
building construction, and hereby authanm representative of this city to cater upon the
mW.-nimakinad properly for laureation purposes. -
(We) agree to save, indemnify and keep humlett the City of Cupertino against
liabilitica judgments, costs and carcases which may in any way acerve against said City
in consequence of the grating of Nis Permit.
- -
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SO CE REGU ATI
Re -roofs
Type of Roof
°
tic unsacmr Dam
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant more of handle harardous material
as defined by the Cupertino Municipal Code. Chapter 9. 12, and tW Health and Safety
ade. Section 25532(a)+�
All roofs shall be inspected prior to any roofing material being installed.
El Y. _
If a roof is installed without first obtaining an inspection, I agree to remove
Wits the applicant of future building Occupant tom equipment or deices which
mit hofaodnus air contaminants u defined by lie Bay Area Air Quality Management
all new materials for inspection. .
Diane" —
1
0 Ys
Ihave real the baraodnus macrials oeyuiremcns under Chapter 6.95 of the Glifor-
nu R.it, Safety Cade, Sansom 2 M5.25533 and 2i53a. i undersmm the if the Wilding
-
dor nor comedy have a temarl that it 4 my msponsibilily m notify the sport of the
requiremc - mu WmmpI I awemfaCentrnmoro�a
Signature of Applicant Date
OS
75:�
- - All roof coverings to be Class "B" or better
owner or aamomee cm Date
wy
CITY OF
01PEkTINO
JOB ADDRESS:
Buil
OWNER'S NAME: G1PClVtO�L Two ,�
GENERAL CONTRACTOR: V3-tfz� t ( o
Community Development
10300 Torte Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Department
PERMIT #
650100
PHONE #
FAX #
I am not using any subcontractors: 114 0
Signature Date
Please check applicable subcontractors and complete the followinv informatinn-
Ow er/ Contractor Signature
Date
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ow er/ Contractor Signature
Date
n
0
a---
C11YOF
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
APN #�j
✓ /
Date:
�Iylug
Building Address:
lot>sqCoh Pl.
Owner's Name:
Phone #:
EI o �e
Sys- $ 3xza
Contractor: % , O
License #: 3 - VS 73
Contact:
Phone #:
Applicant/ r: n I
•
�S, o> 5 q1— /23 z
Building Permit Info:
Bldg Elect lumb Mech
Job Description-
escri tion:
esidential ,Gr% Commercial:
:;",
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:(
,,W m
Type of Construction:
Occupancy Group:
Qty. if
Applicable
Fee ID
Fan rlacrri n/'nn
r7ee !_
/ BENERGY
Energy
BUILDING
BPWHEATER
Water Heater/ Vent
BUILDING
/ PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPERMFEE
Bld Permit Fees
BUILIDNG
BMITIGAT
Housing Mitigation Fee
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
f -s.7CG/I / 1
Sv -2—