04010057 a CITY OF CUPER'rINO t
BUILDING DIVISION PERMIT 1CONTR`ACTOR INFORMATION '
BDILDING ADDRESS: HOT WATER INC PERMIT N904010057
OWNER'S NAME: PERMIT ISSUE DATE
CHT CHANG 9-11 GRACET-AND ANTE:
ONE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTORS der provisions DECLARATION
tt wp 1 Mn 0(D.f that 1 am 11¢nse0 under ndProf Chapter 9(commencing Job Description
fZW wiNScaion]IXXI)of Division 3of NC Business and Professinm Code.aRtlmylicense is
us
.m rale rage andtrrec _ L WATER HEATER REPLACEMENT
j Z License a Liu.a �®
Grp Dam Canuacmr_ FOO®app . Imo®
'a ARCHITECTS DECLARATION E®rgs Ws
¢e lured wand my Pitrsshall lie it u public mends
:,WU
oG Licensed PrOfessional MAR 0 5 2004
5 OWNER-BUILDER DECLARATION
y'y a Z 1 hereby affirm that I am exempt Gum the Contractor's License Law fur the
;p 0 following Manor.(Section 9831.5,Business and Professions Code:Any city ar county
t$ which requires a Permit In ernatun,alter,improve,demolish,or repair any structure tlY./0 Ybs
prior In its issuance.alsu mquira the applicant rorsuch Permit o file a signed statement
-�a
that hat is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. FL Floor Area Valuation -
ytZ-D (cam meneing with Section 7")of Division 3 of the Business and Professions Code)Or
i
that he is exempt tMnrman and the buts for the alleged exemption.Any violation of
Section]051.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 519`V N,RXDt(; O O
not more than fin hundred dollars(5500). i��.xOVaAJ IY r Occupancy Type
❑1,as mvnct or the pmPtny,or my cmployca with wage as their sole compensation,
will do the work.and the structure,is not intended or offend for sale(Sec.]Odd.Business
and Professions Cadc:TM Conncio's License r Law donot apply to an owner of Required Inspections
progeny who builds or improves thereon,and who docs such work himulfor Nmugh his
own cmployca,provided that such improvements are not intended of offered for sale.If.
however.he building or improvement is sold within one year ofcompletion,the awncr-
builder will base the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as Owner or the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7000,Business and Professions Code:)The Contractors Li-
cemc Law docs not apply to an owner of property who builds or improves Nenon,and -
whocontsacts for such projects with a contractor(s)licansed pursuant to he Contractor's .
License Law.
I mo ci crept undo,Sec. .B&P C far this..a
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby aR,m under,Penally of perjury Om or are following declarations:
1 base and will maintain•Certificate of Consent to til bimare for Warkn's Compere
tion,n provided for by Section)]W of the Labor Code.for the performance of the
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance.m required by section
of the Labor Coil ,for the PCRormancC of the work for which this Permit is issued. '
My Worker's Compensation Insunn¢cartiec and Policy nun rare: ��
Carrier.
C�A (/I-"I Policy No.:�
��Rr KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not M complaed if IM permit is for one hundred dollar(SIttO
Mass)
I anify that in the performance of Ne work for which Nis permit a named.1 shall not
employ any person in any manner sen as to become svbjta to this,Workers'Compcnaadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cenificale or Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code.you must
wJ O kolhwiLb comply with such provisions Or this permit shall M deemed revoked.
vy CONSTRUCTION LENDING AGENCY
[-+ I hereby alarm that Note is a construction lending agency for the perfurmance of
a the work fur which this permit is issued(Site 3099,Civ.C.)
W Q fender's Nam,
z UnderS Address
U
U Q 1 certify that l have,cad this application and atom that the above ws mining to
0 U sodden.1 agree to comply with all city and county ordinances aivesor his slam laws relating N
V anon-gearmnctism,and rtylranim,eumnprepreaenutimsof this coy to cnmralMn Nc
} abavr(We)agree
propane fm iospcni an keep ha ^
(We)agrte to cast,indemnify and keep hay in an w City accrue
Cupertino iagainst
d City 1
UZ liabilitia,judgmcnhecosts min,carcasses which may in anyway scene ageinslsaid Coy
U Z A APPLICANT
or UNDERSTANDS
of this AND
/
^-� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCES^GU TI s. a
Re-roofs
HAZARDOUS
Signature fApPliaDa
HAZARDODO US MATERIALS DISCLOSURE Type of Roof
Will the applicant or,Muni building dcc ha ter9.1of handle h Health
material
u M.V by IM Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
cads.s,Non zsszz(a>+
❑Yes �(No s� All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant mo equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
at tomo ms air contaminants allied by lM Bay Area Air Quality Management all new materials for inspection.
aria0
oh
El
plisse rad Ne huvaNnas mamrials myviremcnts under Chapter 695 of NC Califon // //�� _ p�
diaHalth uacoll he
-0 Mount,
oto it i my reind355J0.l to ursmnd a acCur Milding ,/[`/'
docs not curenlly have a mnant Nat it is my rexpunsihility,m nntily IM¢cupanl of the C/
reciirement qma mel darmiaaaantenracenucamo Ixcn Q Signature of Applicant Date
Owner or amtlowzd agent ,e All roof coverings to be Class "B" or better
CITY OF CUPERTINO o �S
WATER HEATER 7
CUPF
CITY
PERMIT APPLICATION FORM
APN# o-Z� Date:
Building Address:,)
Owner's Name: Phone#: 3�
IfAX
Contractor: Pho License#:
Contact: P one: Cupertino Business License#:
tS ��Lo31- g�1
Building Permit Info:
Bldg ❑ Elect ❑ Plumbo Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:f, b
Strapped ❑ On Platform LJBonded L1New Location E3Replacement
Qty. if
ApD6-9able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE PlumbinR Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2
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