03100034CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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RmLDINGADDRESS:
ALL VALLEY, PLUMBING
PERMIT NO. 03100034
OWNER'S NAME:
170 BRANNON DR
PERMIT ISSUE DATE
HE
NE:
(510)376-4816
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
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I hereby affirm the, 1 am licensed under provisions of Chapter (commencing
with Section 7ME of Division 3 of fie Business and Professions Code. and my license is
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REPLACE WATER HEATER o
License - Lic.g -
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ARCHITECTS DELL A ION
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I undcrata shall i used as
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Licensed Professional
OWNER-BUILDER DECLARATION��I
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1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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fallowing reason. (Section 71131.5. Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
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prior In its Iscuonee, also requires the applicant rot such permit to rile a signed statement
Sq, Ft. Floor Area
Valuation
that he is licensed pursuant to the pmvismnsof the Contractor's License Law (Chapter 9
(commencing with Section 711f1(gof Division 3 of the Business and Professions Code) or
that he Is exempt therefrom and the basis for Ne alleged exemption. Any violation of
35924044.00
APN Number
Occupancy Type
Section 70]1.5 by any applicant for a permit subjects fee applicant to a civil penalty of
not more then Eve hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
bU2 —INALJIM CtWSEHGY
will dm the work, and the sbuclure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Comlmmors License law docs not apply to an owner of
5 0 6 GAS TE S
properly who builds or improves Roman, and who doessuch work himself or through his
-
own employees, provided that such impetsormntl nei intended moffenad fmsale. If.
507 — FINAL PLUMBING
however, me building or improvement is sold within one year of completion, the owner
builder will have Ne burden of proving that he did not Wild or improve for purpose of
I, as owner of are property, am exclusively contracting with licensed components to
construct the project (Sec. 70", Business and Professions Code:) The Contractor', Li-
ccnse law does not apply to an owner of property who builds or improves menton, and,
who contracts for such projects with a contractions) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ow of the following declmalion o
1 have and will maintain a CeRificep of Consent to self-Insure for Worker's Compcn-
andury as provided for by Section 37W of the labra Code, for the performance of the
-
w rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
'
37W of be Labor Code, for Ne perform too or the work for which this permit is issued,
My war c t nm ansa iter random artier end Policy number am:
C cr, ! Policy No/
CERTIFICAT OFXEM ONFROM OR C
COMPENSATION INSURANCE
(Thissecltoonced noticrandeu i ifthe pormilisforonchundred colors(SIM)
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orlcssJ
1 certify that in the performance of the work for which this permit is h eucd, I shall nut
employ any person in any manner an as to become subject o the Workers' Compensation
Laws of California. Date
..
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Cam pensation provisions of the labor Cook, you must
forthwith comply with such provisions or this permit shall i deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aMrm that tRere iso consuuctinn lending agency for the performance of
,he work fur which his permit is issued (Sec. 3W7, Civ. C.)
Lender's Name
.
Lender's Address
1 oenify Net 1 have read this application and sant that the above information is
cored 1 agree m comply with all city and county ordinances and apse laws relating to
building construction, and hereby allasmire repmucaudivca Of this city to enter upon the
ahove-mentioned property for inspection purposes.
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(We) agree to save, indemnify and keep harmleas the City of Cupertino against
liobi Ellis. judgments, costs and expenses which may in any way acerae against said City
I. conscqucncc of the gran' f thispermit.
APPLICANT UNDER DS AND WILL COMPLY WITH ALL NON-P N
Issued by: Date
,.SOUR RE•GULAT S.
Re-roofs C7
Type of Roof '
c canl/Commcror
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Lir future building Occupant store or handle haaardous material
.
as carload by the Cupertino Municipal, Cod, Chapter 9,12, and the Health and Safely
Curie. Section 25532(a)?
All roofs shall be inspected prior to any. roofing material being installed. "
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orf tore building occupant use equipment or devices which
It haaardnus air crelpar ran m dcOncd by the Bay Arca Air Quality Management
all new materials for inspection.. -
Wray?
❑Ycs u
Ihavereadtheiaando a materials requirements under Chapter 6.95 Of the Califon
niu Health&Safety Code, tins 25505,25533 and 25534.1 understand that if the building
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does not cremly have nant, Not it is my noliossibilky m meaty the cecupartt of
of,whic ,time ria olssdancenfa Cerdficacif asp
Signature of Applicant Date
All roof coverings to be Class "B" or better
am orped agent Dam
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PERTINO
CITY OF CUPERTINO
WATER HEATER 3
PERMIT APPLICATION FORM
APN #
Date•
359-71I-
9
Building Address:
Owner's Name:
Poe #:
61W ar-mysOS
Contractor:
Phone: d
Li�gnse #:
D
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Contact*
P ne:
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Cupertino Business License #:
/ sv -90
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Buildin�d�
Bldg ❑
Elect ❑ Plumb
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Job Description:
Residential IV
Cnmme.minl r-1
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Cost
Cost of Project:
Bonded
New
Appliqakle Fee ID Fee Description Fee Group
BPWHEATER Water Heater / Vent BUILDING
tPPERMITFEE PlumbingPermit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING
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