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03070165ymZ Dp sq= n �ggqqqq�yy p0 FZA ec E�R FIt z z N UO_ OFLLI W U �Ok ty_t I CITY OF CUPERT[NO z ^ g BUILDING DIVISION PER 7� ♦dry j�' l'T COl\RMVTORFORMATIy1'A ��. auILDINCi ADDRESS: 1A1 C-RESTITNE MR WATER HEATERS ONLY PE ""030%0165 OwNER'S NAME: 970 E. MAIN ST, SUITE 200 PBRMIT ISSUE DATE ONE: (800) 835-5946 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BILDOO ELECTO PLUMB MECHO LICENSED CONTRACTOR'S DECLARATION Job Description I Wrens, affirm that I am licamad under provisions or Chapter 9 (commencing i) wit Section 71)M) of Division 3 of the Business arms Pofesainnx Cnde, and my license is in LicfemmC andeffea. Lit.a WATER HEATER REPLACEMENT FBUMb%I„ Dau Contra me ARCHITECT'S DECLARATION 1 understand my plans shall he used a public accounts J U L 2 2 Z003 Liccnmd Pnrftasional OWNER -BUILDER DECLARATION I hereby affirm that I em exempt from the Contracmus License Law for Ins 1 f 1L 1"1� p N g^ D BUILDING 1 following maron. (Section 7031.5. Business and Professions Cade: Any city our county U/ W which ,comms o Permit ,, cows,, alma improve, demolish, our repair any suuctum prior to its Issuance. also astmo'31he applicant for seen Permit to file a signed statement that he is licensed pursuant o the previsions oflW Contractor's Limo Law(Chaptm9 Sq. Ft. Floor Area Valuation (commencing with Section 7flflo) OfDivision 3 of One Business and Professions Cade) or 36225002.0 that he is exempt ineofmm and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by o^9 applleAM(Or • Permit subjects to applicant to a civil penalty of not mom ten Bvc hundred dollen (S5M. ❑ 1, as ...,of da pmpeny, or my..pl.ycm with wegea as tela sole compensation, — NAL �LJg I�3P' C RGY will do to work and testrucum, nmol iruxu or offered fatale (Sec. 7D04, Business Code: and Profusions The Contractor's License Law does Out apply u in owner of property who builds mimprowa desmon, and whodocaauch work himself., though Ms 5 0 6 - GAS TE 5.•111 ownemplayter. provided that aueh improvements..at intended Marercd for sale. If. 507 — FINAL PLUMBING however, to building or impovement is sold within arc year of completion, to ho ma. builder will have the Wrden of proving tet m did not build or improve for purpose of sale.). 1, as owner of the property, am exclusively contracting with, Ilcenmd contractors to o son the project (Sec. 7014. Business and Professions Code:) The Contractor's Li. ' came raw dos not apply 10 an owner o(propeny who Wilds m improves ft.. and, who contracts for such projects with a contractor(s) handed pursuant to the Comractoe. License law. I erp'EiV pt P C fnrthis moon O 0—I, �u � WORK OMPE SATION DWE52IION 1 hereby aflimt under penally of p do, ane of to following declantiom: 1 hese end will maintain a CeNBata of Consent to ulRinsum for Workeh Compere lion, as provided far by Section 3700 of to Later Codes (or to performance of the work for which this permit is Issued. ❑ I ham and will maintain Workaf s Compensation Insurance. as R4ulmd by BCCllon 3700 of to Labor Code, far tW performance of to work for which this permit is issued. My Worker's Compensation Insurance artier end Policy number am: Cartier: Policy No.: CERTIFICATE OF EAEM MON FROM WORKERS' COMPENSATION INSURANCE Missecllan arms not m completed if dee permit Is foram hundred dollars (SIM) our less.) 1 certify that in the performance of the work for which this Permit is issued, I Nall not employ any person in any mannerso as In become subject to the Workers Compensation Lows of California. Data Applicant NOTICE TO APPLICANT: If, Arer making this Certificate of Exemption, you should became subject to dle Worker'. compensation provision of the labor Cock. you must forthwith comply with such provisions or this Permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY I hemhyaffom tm them is a C(ohno IMM lendinggetrcy far the perfomarmcc of to work for which this permit Is issued (Sec. 3197. CO. C.) Lender's Name 4 dcr's Addmss I certify tet 1 have aced this and area that the above cos rchums is Carmel. I egret m comply with all city sod county ntainanaa and sou hews relating city and county building construction, and hereby euthorim representatives of this city to enter upon to,he anovbmeminned progeny (in im an pue ' p ha egme to cove, Inde xpen and kap harmless the City of Cupertino against indemnify (s judgments, which tory in any way emrm against aid City judgmentse costs end of to gaming of to in consequencealibispe Aconsequence D WILL APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date s0 EREGU TIONS. Re -roofs at ignature of Applic Contract., Dam ARDOUSMATERIALS DISCLOSURE Type of Roof Will to applicant or fuum building occupanl sore or handle harerdous material as scOned by the Cupertino Municipal Code, Chaplet 9.11, and the Halt and Safety code. Section 25532(a)7 / All roofs shall be inspected prior to.any roofing material being installed. Nu ❑taro WIN. -If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or orate Wilding occupant sex equipments devices which It homntous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. raic,7 ❑Yes p%Nn I have mash tc Wrudous materials mquimmcou under Chapter 6.95 of to Califon hie Hesllh S, Safe,, Cocke Sections 15915.8533 and 25534.1 understand tar ifthe Wilding does not currently have s mount. tet It u my mapomihility M and IW acupant of to mquimryEq�xwhie aatMymg rta��encemfimmofOcc. y. Signature of Applicant Date Old All roof coverings to be Class "B" or better vent, air antorised m Date C. OCITY0 CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM �3 � 7J/ 6s' APN # 3 G Z u o 2_- Water Heater / Vent Date: � 2-1 -0 BuildingAddress: I I $1 G(L�4TLr N� !Jr Cc.k Coq i S D l y Owner's Name: J04 �� � Phone #: G Y q � 3 0� Q4 Contractor: &rf�! on License #- :5 -�E�� Contact: Phone: S� Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ lum Mech ❑ Job Description:R� r Residential J Commeipal I ❑ Cost of Project: Strapped El On Platfo B nded El ( 6 13Re New Location lacemenE Qty. if Ap ica a Fee ID Fee Descrintion Fee Grouo BPWHEATER Water Heater / Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING -Z2 M.