06020124 CITY OFCUPERTINO
BUILDING DIVISION PERMIT tCfSNTRACTUR INF'O'1tMA."CICI.
BUILDING ADDRESS: RO IIF1
S CONSTRUCTION CO MND.06020124
�• 10255 S DE ANZA BLVD
WNER'S NAME: PERMIT ISSUE DATE
ROBERT ALLARIO 3575 STEVENS CREEK BLVD 02/22/2006
NE: SANITARY NO. CONTROL NO.
(408) 296-5926
ARCHMECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 heLIC ENSEDCONrRSDECLARATION JbDescription
rd 1 hereby Alarm Nal I sin Ecenodunderunder provision of Chapter 9(Commenceo
s q
with Section 70fIUa Division 3o(Ne Business and Profession Code.and myliccnse is INSTALL GAS WATER HEATER a(�j
nppp in full forte and effect Q
j LicensuClw Lw.conr
Da¢ ComracC 1
` As MH
DELLA 1
L I undersand my plain shall M used As public records ( qp
kQ
Licensed Forestal onel �� t(� av(�/,.
`y
OWNER-BUILDER DECLARATION ff�)/l[(/r
)hereby affirm Net 1 am exempt from shmmd
e CooYs License Lew for the 6f
C p o following mann.(Section 7031.5,Business and Profession Cole:Any city or county ( ser�� dys.51v
$ which myuircs a permit to counsel ales Improv,demalah,ar¢pelt any awcturo /5
�^ prior to is issuance,elsu requires the applicant furtuch permluo Ole a signed stsmment
EG Nal he is licensed pursuananthe provialonn
nftheComracmLicenseLaw(Chapter9 Sq. Ft. Floor Area Va1ua[ipn
m $ (commencing with Section 7000)ofDivision 3 of the Business and profession Code)or
Nat he a exempt therefrom and the buss for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the Applicant,o a civil penalty of r Occupancy Type
not mom than fin hundred dollars(5500).
❑1,As owner of the proprny,or my employee with won as Near sulk compnation,
will do the work and the structure is not intended oro@ted per stale(Sm.7W.Bussrcas Required Inspections
and Profesdon Code:The Contrcwn Lictom Law doe not apply w e ns an owner or q p
property who builds cr(meows thereon,and who data such wort himsel f or through his
own employee,provided that such Imprmemen0 are not InWbed moffered for Aske If.
however,the building or improvement B sold within arc year of completion,the Owner.
Wilder will haw the burden of proving that Its did an build or Improve for purpose or
Asked.
❑1.As Owner of the property.am esclufively comracdng with licensed cenvamars to
cuntnet she project(Sec.704x,Business and Profession Code:)The Cont actts's Lb
cense law does not apply in an Carer of property who builds or improwa thereon,and
who contacts far such p njeca with a Containers)licensed pursuant to she Contractor's
License law,
❑I am exempt under See. ,B h PC for this mason
IMy
ner Date
WORKER'S COMPENSATION DECLARATION
I hereby of in a under penalty of perjury one of the following declaration:
1 how and will maintain a CeniBntc of Conant to self-ilium for WorkOrsCompm-
on.u provided for by Section 37M of the labor Code,for the performance of the
rk for which this permit is Issued.
1 have and will maintain Workers Compensation Insurance,u required by Section
ql of the Labor Code,for the Performance of the work Int which this permit is issued.
Workers Compensation Insurance tinier and Policy number am:Mer.
S7 4TF Policy No.: q zc-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thio¢Nan need not Wcompleed If the Permit is foronc hundred dollars(2100)
m leu.)
I certify that In the performance of the work for which this permit is issued,I shall not
employ any person in any Wootton,As b become subject to the Workers'Comprwdon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this CertiOew of Exemption,you should
become subject W use Worker's ComPewtinn provision or the labor Code,you muss
,J z foMwish Comply wish such provision m this permit shall be clamed revoked. -
Z► CONSTRUCTION LENDING AGENCY
(—i l hereby affirm that them is a construction lending agency for Oc prfurmeme of
ai
the work far which this permit Is iuwd(See.309E Civ.C.)
0.Q Lenders Name
z Lender's Address
C)Q 1 unify that I haw mad this application and!show Nat she show information Is
IT•E correct.l agree to comply with All city and county ordinances and AMC Iowa relating to
C) building convection,and hereby sumodm oprosenatiws of this city to Omer upon Ne
G ahow-romanned property for Wpction purposes.
(We)agree to save,indemnify and keep harmine the City of Cupertino against
in In Eabllitie,judipano.cosu antl exponses which may in my way acme against mid City
U APPLIs YMIL CANTOUNDEof the RSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by:. Date 2-, Z
SOURCE REGULATIONS.
Re-roofs
Signarurc of AppheanVComrDOr Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building acupantstmc mhandie huudous material
As defined by the Cupertino rMunicipal r.Chapter 9.13,and the Health and Safety
de,Otion Ye]Ss3z(g7 �N All roofs shall be inspected prior to any roofing material being installed.
.I No
Will the applicant or f]utture building=upon,use equipmml or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havardous air comammunts as dcfncd by the Ray Arca Air Quality Management all new materials for inspection.
ld�
dint
❑Yes �No
I haw rr��,,LL c heaardaus materials rcquiremenu under Chapter 6.95 of the Claim.
Hoa1011, cly o atimu 23505,75533 and 25534,1 undcrsaed wuifN,building t
t can ndy have•t anL Nu It a my responaibilitY m rwtifY Nc aaupmt of rive a-
u1 menus hich most met poor w issuane,era crnifrcate orrar1pmag9 Signature Of Applicant Date
66 All roof coverings to be Class"B"or better
ner or amhariad agent hoe
J
s Community Development
10300 Torre Avenue
4 ✓' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JO fO ZSS —r �!v PERMIT�02 O < 2_LI
-u C C� /
OWNER'S NAME: 1— ora PHONE # $ �Z
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T'
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
3S( / 6v
Building Address:
/oris S /DeA 4 ?— A i3/ u j
O per's Name: Phone#:
7 Lln R t
tractor: Phone:c/a!' Z G 6 �d G License#:
� f/— 4'69 S 2
Contact: Phone: Cupertino Business License#:
ati PAR LS
Building Permit Info:
Bldg ❑ Elect C Plumb Mech C�
Job Description:
/ /J C%q
Residential ❑ Commercial
Cost of Project: 43� d
• Strapped PJ On Platform 0 Bonded El
New Location Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE. Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
3.3 �