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CITY OF CUPERTINO
BUILDING DIVISION PERMITG`UbiTRACTUR;T�MA'CIQ�1V•",;
BUILDING ADDRESS:
Q100 CRESCENT ED
AFFORDABLE WATER HEATERS
"""�ND' 05120076
OWNER'S NAME:
PERMIT ISSUE DATE
IGAHE DJAFAR AND GOLESTAN
24707 SAN FERN
2005
NE:
SANITARY NO. CONTROL NO.
(661)259-7131
ARCHITECT/ENGINEER: -
BUILDING PERMIT INFO
EO PLO MEOCH
Job
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LICENSEDCONTRd DECLARATION
Job Descri IO ®
under9 (commencing
affirm (hativid 1 am Ikensed undo provisions
1 herion
w
xoCTade.
Section 7IXD)ofDivitlon Sof tint Businessand Pmfculona Code. and mylicense u
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m fend mrce a eqe t.
Lkenab Clan Lk. a G27.�G 8
WATER HEATER J
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Dam COnDEC PC ^nnA 1 +�
ARCHRECsS DECLARATION
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I understand my plans shall be used as public records
(j s,
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afOrm that 1 em exempt from the Curbstone, License Law for the
l�pjVq��'y
following reason. (Section 7031.5, Business and Professions Code: My city or county
Up+Jlre
which requires a mos it m constrocL alter, Improve, demolish. or repair any abrasion,G$400
Prior In Its iuuanec. also requires lite applicant for such Permit m file asigned statement
that he is licensed pursuant o the provisions of the Conmamr's Lkeme Law (Chapter 9
Sq. Ft. Floor Area
Valuation
u Busiocand Professions Code) or
(commencing with Section 7000) of Divbion 3 of Nu
Nat haes, exempt the almm and the bub for the alleged exemption. Any violation of
r
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not more than fivehundred dollars (5500). ,
❑ I. as owner of the property, O my empdoyeu with wages as their able compensadon,
Required Inspections
will do the work, end the structure is not Intended oto@rsd for aau(Sax. 70th, Business
,ad Padmat.ns Cade: The Contra ar's License Law does ret apply m an Owner of
9 P
property who builds or Improved, thermn. and who dms,tech work himself or tiuough his
Own employers. provided Ihatsaeh Improvements are malnended oOEmed for sal. If.
however. the building or improvement is sold within ane year ormmptetion, me Owner.
Wilder will have the burdan of proving that be did not build or Improve for purpose of
sale,).
❑ 1, as Owner of the property. am exclusively contracting with Incensed mnuaa7Os to
roue= the project (Sec. 7044, Buineu and Pro(essiou Cade:) The Contractor's U.
cane Law does not apply In an Owner of property who build& or Improves themon. and
who caneacu for such projects with a camracmrts) licensed pursuant to the Conmw.To/s
License Law.
❑ 1 am exempt under Sec. . B Ss P C for this ration
Owner Data
W ORKER9 COMPENSATION DECLARATION
1 barely allunder penalty of pedury, ane of the following declarations:
1 haw and will maintain aCcrdfinteof Consenito sel6lnaum for Workefa Compen•
nation, u provided for by Station 3700 of the labor Code, fear the performance of the
work for which this permil Is iuued.
❑ 1 have and will maintain Worker's Co npewdon Insurance, as required by Section
3700 of the lahor Code, for the petforma en of the work for which this permit is bound.
'
My Workefa malmasation Insurance carrier and Policy number are:
Cartier. �'�"�✓^� Policy NO.:
6
CERTIFICATEOFFXEMFDON FROM WOR .RK R
COMPENSATION INSURANCE
07M, section need not be completed ifthe permit Is far onehumbereldollars (SIM)
or ksa)
1 certify that in the performance Of the work for which this permit Is issued, I Ghali not
employ any person in any matter an as to became subject to the Worked Compensative
Laws of California. Data
Applicant
NOTICE TO APPLICANT. If. aper making this Certificate, of Exemption. you should
become subject in the Worker's Compensation provisions of the labor Code, you mum
(Onwith comply with such Provisions Or this permit Mall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hesehY alfirm that there is a construction lending agency fm the performance of
the work for which this permit Is Issued (Sm. 3097. Civ. C.)
Lender's Nam,
Lendefa Addrus
1 certify that I Mw reed Ws application and sum that the show information is
costed. I &Sree in comply with all city and county ordinances and mute laws relating to
Wilding construction, and hereby suthnrixe mpresenutivcs of this city m enter upon the
abovnmenlioned property for Inspection purPoes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities. judgments. nom and expenses which may in any way amuse against aid City
In eov emonsC Of the Starting of this permit.
APPLICAnNNT UNDERSTANDS AND WILL COMPLY WITH y.1. NON -POINT
SiSna�REGIe,r N� -r
Issued by: Date
Re -roofs
Type of Roof
/2//y/0
signa. ofAppIlesWCmanwmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant more rehandle banned. material
M defned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Olc. SOYoonn 255320)7
All roofs shall be inspected to any roofing material being installed.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will do applicant or furore building Occupant use equipment at devices which
it huvardous air contaminants M d by the Bay Amo Air Quality Management
all new materials for inspection.
bWOT
❑Yes Nu
I haw rod the hm
uasdous mrialsrequhements under Chapmr6.95 of t e Califon.
ole Hulth AS rcty Cade,Sccdau253(15,25533uo125534.Iundesmndthaifde halding
docs am curmn11 haw a Is it is my ms uihilitymtm.ly the Occupant of de
rcyulrtman t m jriafmima r i se.raeapan
Signature of Applicant Date
_ > 2�iy�
All roof coverings to be Class "B" or better
es
Owner
r auNorixed agent
teDam
11/23/2005 08:49
66122599556
AFFORDABLE WATER HET
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
PAGE 02/03
O,S/ate �
APN # ?aae� A/
Water Beater / Vent
plumbing Permit Issuance
BUILDING
PLUMBING
BBNERGY
BUSLdC
Building Address:
�•
I b1 Ob Cre.�c_e.nr
Owner's Name:
? ,u
Phone #:
Lt og- a53
Contractor:
Phone: 1<la 1
License #:
worJo6le a 20rtrs
,51-713 1
(va67 3
Contact:
Phone: (P61
Cupertino Business License #:
Coif L -i 1T I e,(:i P- i
ASA -0540
.4(0KO
Building Permit Info:
Bldg ❑ Meet
Plumb
Mech
Job Description:
RePIGC.e anon
WA'ref b1eA'ier
(Sq me. IoCar�vn
Residential Ed Commercial
Cost of Project: W o 0
Strapped On Platform D Bonded
❑ 02",
New Location Leplacement
Qty. if
rn
Rae TIeemt-&inn
,
BMSA` ER
pPBRNffME
Water Beater / Vent
plumbing Permit Issuance
BUILDING
PLUMBING
BBNERGY
BUSLdC
Ener
Business License
BUILDING
BUII-DING