04010009 TCI'I'Y OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORINFORMATION
tea.
Bu R-DING ADDRESS: WATER HEATERS ONLY f PERMITNO04010009
A4-7 7T)MTNTTr)N IDR
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARY N0, CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
°oo LICENSED CONTRACTOR'S DECLARATION tl=III NALED
O
Wp 1 hereby affirm that 1 am lice sed undis o U bsrtr Cs� 9(commencing Job Descrip
�W wimSection]exp of Division of the Businc MPrf and my Pic se
in full force and c i.
;�'y3 Licensee " L EPLACE WATER HEATER0 Do
JAN 2 2 2004
W ARCHITECTS DECLARATION
u 1 understand my plans shall W used es punlic rtenrJ.a
eurst7, Licensed Pmafffessinnal BUHMIq�G
OWNER-BUILDER DECLARATION
.�<$ I hereby rm that I am esempt fru.the Contractor's License Law(or the _
—O o following reason.(Section 91131.5,Business and Pmfc,skins Code:Any city nr county
s m which requires a permit to construct.alter.improve.demolish,or repair any structure
uiy prior to its issuance.alio equines the applicant for Such Permit to It le a signed statement
<
that M is licensed pursuant in the provisions of the Contractor's Uccuaw Law(Chapter 9 Sq. Ft. Floor Area Valuation
yo (commencing with Section 7000)o(Divixion 3 of the Business and Professions Coded or
i that he is exempt themfro n and the basis for the alleged exemption.Any violation of
Section]831.5 by any applicant fon permit subjects the applicant to a civil penalty of 37�PE]�jpgl�rYr00 Occupancy Type
not more than
five hundred dollars P Y YP
❑1,as owner of the property,or my employees with wages as their thin compensation,
will do the work,and the structure is not intended or offend for sale(See.1014.Business
and Processions Code:The Connector's Limma,law dos not apply in an owner of Required Inspections
property who milds or improv daemon,and who does such work himself or through his
own employees,provided that such improvements arc not intended Proffered for sale.IL
however,the building or improvement is sold within one you orcompletion,the owner.
builder will have the burden of proving mat he did not Wild or improve for purpose of
sale.).
O h as ownef of the p upcny,am cmlusivcly cvn wing wish licensed contractors to
construct the project(sec.7W,Business and Professions Code:)no Contractors Li-
aiso Law does not apply to an owner of property who Wilds or improv the.on,and
who contracts for such projects wish a conteector(s)licensed pursuant to the Convectors
Licca¢La-
0 1 an,c.empl under Sec. ,B A,P C for this anon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury Pon of tW following decleradma:
1 have and will maintain a Cenifeate of Consent o self-insum for Worker's Compere
ration,as provided for by Section 37W of the LOW,Codc,for the Send mmance Pf tic
for which this permit is issued.
ve and will maintain Worker's Compensation Insurance,as ayuiatl by Section
10(1 of me labor Code,for the performance of the work for which this permit is issued.
My Workers Cnmpen�s3Jr lns/y/sans cavicr and Policy number a am: /—. �Y
Carrier: S ! V'r Policy No.: /�1 ST �+✓
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not P,completed if tle permit is rmonc hundred dollars(SI W)
Or lora)
I candy mat in the performance of the work for which this permit is Paned,I shall not -
employ any person in any manner so az to become subject to the Workers'Compensation
Lava Of California.Data
Applicant
NOTICE TO APPLICANT:If,•ficr making this Cenificatu of Emmpion,you should
become subject to the Worker'a Compcnmlion provisions of the Leber Code,you must
.J O fonhwiIn Comply with such provisions or this Permit W deemed revoked.
Z � CONSTRUCTION LENDING AGENCY
P:Z; Ihereby affirm that there is a construction lending agency for the performance of
rt.
On work(ser which this permit is issued(Sec.3097.Ci,C.)
W tender's Name
tender's Address
� z
U 0 I cenify that 1 have read this application and sun that me above inromatiun I$
gL F conal.1 agree to comply wit all city and county ordinances and state laws relating n
OU building construction.and hereby authoin representatives of this city to enter Open the
IS] ahove-mentioned properly for inspection purposes
Fy (We)agree to ase,indemnify and me,harmless the City of Cotenina against
fin liabilities,judgments.costs and expenses which may in any way accrue against said Ci Ly
U {Z in consequence of the granting of this permit.
^� APPLICANT UND RSTANDS ND LL COM Y WITH ALL ON DINT Issued by: Date
SOURCE REGU IOSyS a
_ ���" '`'�"�"t� `L Re-roofs
Signature oltApplicaHAZARDO —p�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof I
Will the applicant Or future ipal Cg occupant store or handle naallous material
az def nctl by me Cupertino Municipal GPde.Chapar 9.12.and due Health and Safety
Pdc,Semm�2, "id, - All roofs shall be inspected prior to any roofing material being installed.
�Ves ON.
Will the applicant or future building Occupant use equipment in Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
in hanrdous air contaminants as defined by Be,Bay Area Air Quality Management
iuricR all new materials for inspection.
❑Yes 0 N
1 haw read the Waarshms materials requirements under Chapter 6.95 of the Califon
niaF almhSafciy Codc,Sccdum25X)5.25533and35534.Iumbriondthatiftic Wilding
does tool currently M1 tenant the it i y rtsPu�yl,�hc�, ,,,Pfdoc
nom remcno'witur�bcm i nonce orSignature of Applicant Date
authcoccl eel ' ' All roof coverings to be Class "B"or better
IL
CITY OF CUPERTINO
um WATER HEATERDO
CUPERTINO PERMIT APPLICATION FORM
APN# 375- Z z-
Building Address: ! F_y 5 7
Owner's Name: L � L Phone#:
"""�-�•� 2-5 5 - v 5 q
Contractor: O License#: 3 e/S 3
Contact: Phone
�-w c`loo ,' -3s
Applicant/Certiaetor:
1'J �510> /Z3 -.L-
Building
Building Permit Info:
..Bldg Elect lumb Mech
Job Description:
esidential �LrJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Descri tion Fee Group
/ BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE —Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG