05090198 CITY OF CUPERTINO
n "PION"
BUILDING DIVISION 'OTORINFOR
PE MIT
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LDING ADDRESS: HOT WATER INC PERMIT N005090198
607 ERIN WY
NER S NAME: PERMIT ISSUE DAM
SUZAN LAU 2531 GRACELAND AVE 09Z29/2005
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ADDRESS:
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SUZAN I
NE SANITARY NO. CONTROL NO,
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED
liz
LICENSED CONTRACTORS DECLARATION
rd ii C who if increby affirig�m I-
10 to�Coon 7.):'Division I
I farm and 'T cr�
I toneby affing that I am fluccomd under provisions of Chapter 9(commencing Job Description
With SmLion 7")ofDivWon 3 ofthe Businegarad Profissions Code.and my license is
REPLACE WATER HEATER/SEISMIC RESTRAINTS,
in full to=and cffi� 0.
is "'emse Chain
me
,tj� License Class Lie.
_ Dow CT P. EXTERIOR
aq ITECTS DECLARATION
W used as Public records
,no'c
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Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from do,Contractor's License Law for the
OO following mason.(Section 703 LA,Business and Professions Code:Any City or county
E
.,S� which miquiren.aging to construct,tiller,improve,dcatorem.or repair any structure
4zOz poor to is issuance,also requires the applicant for such .I I to file.signed summer(� Sq. Ft. Floor Area Valuatioi$500
that Ive is licensed promant to t1be provisions of dic Connector's License,Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Pondessiorat Code)or
that he is exempt therefrom and Our basis for the alleged exerimptivorn.Any violation of
Section 7031.5 by any applicant for.permit subjects dor applicant to a civil Penalty Of APN Number Occupancy Type
not more man fin hundred dollars(S500). 35920016 . 00
0 l,mo ncrofNepmlx y.ormyemplo awi6wgesuftirmlecompenudon,
will do the work,and the structure is not intended or offered forsaim(Sm.70a4,Business
irri
and Pficagions Codc:The Commaxtor's Licams,Law dcox not apply to an owner of Required Inspections
property who buildsorimprover thereon,and who does suchomals himself or through his
own employees,provided that such improvements are not intended oroffered for sale.If.
however,line building or improvement is mid within one year ofcomplefion,the owner.
builder will have the burden of having that he did not Wild or improve far purpose of
sale
I.as Owner of the,property,am exclusively contracting with licensed conummors to HN11-11ED
Construct the project(!lee.7W,Business and Professions Coda)DO Consomfor's Li
cense Law does mot apply in an owner of .,.y who Wilds.,hOpmomi domix.n.and.
who contracts for such projects with a confromon-4)licanded pursuant to the Contracton's OCT 21r 2005
Liums,Law.
EI I am exempt under Sec. _.B&P C for this rescron
Dome, Dow
WORKER'S COMPENSATION DECLARATION
I hereby affirin under Penalty of perjury one of the following decimations: BUIUM
I him and will maintain a Cernifiento of Consent to self-insure for Warker's Com,en-
tion,as;provided for by Section 37M of the Labor Code,for me performance of the
work for which this Permit is limit.
0 1 have and will matiough Worlier's Compensation Insurance.as required by Section
37W of the Labor Code,forme orforriguracc of the work for which this permit is Issued.
My Workc�aom Insurance Carrier and Policy number no,
Carrier. Pol!,No.; h54T3V6__ 2e0C
CAM OF EXEMPTION FROM WORKERS'
I COMPENSATION INSURANCE
(This setting need not ketimplound ifflum Permit is forrac hundred dollars(5I00)
torlen.)
I Certify that in the performance of fire work for which for Permit is issued,I shift not
employ any person in any manner an OS to income Subject 10 the Warloms'Compemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccitificau,of Exemption,you should
Wcome subject to the Workers Compensation provisions of the LaInur Code,you mug
Z forthwith comply with such provisions or this Permit shift W deemed ogalmd.
z 0
CONSTRUCTION LENDING AGENCY
Fsem. I hereby orfO.that thate is.mi.ti.a.bridint,ligancy,Im the,performance of
the work for which Box permit Is smad(Sm.3D97,Ci,C.)
lender's Name
z Loaders Add.
U 0 1 Cenify that I have read this application and sum that the man finfingaVion is
D, P: Cancer.I agree to comply with all city and county ordinances and mare laws relating to
0 U building construction.and thereby authorin representatives Ofths City to enter upon the
W adram mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep homiest the City Of Cupertino against
,,, Liatoliderjudipurcints,costs and ca,mons which may in any way accrue against mid City
U Z in of do,graming of this Permit.
APPLICANTconsinquenco UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date e-1-f-'es—
SOURC EGLLL
C L'6514--kL 9/A'7/05' Re-roof,
signature Ol'ApplicamurCuerr I Dod.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
All Inc applicant Of future building Occupant store or handle hazardous material
Defined by firm C1,agdom Municipal Code.Chapter 9.12.and the Health and Solely
C Section
L
ode. r-I Yes All roofs shall be inspected prior to any roofing material being installed.
Will thea I plicant 6r future building I Occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air Contaminants an defined by Inc Bay Area Air Quality Management all new materials for inspection.
c3ye'
I have mial the onaccluma materials requirements molarChmmi-6.95 of the Califor-
his Hcaddhis SafctyCock,Sectime25505.25533 sund!255M,1 understood thistrifilic Wilding
I
does hot currently haw a move.that it is My respOsobiloy W notify ft OmIllound Of din
rxq�uOn
=n�which u etpoor( Ccmfij of OCCOpany. Signature of Applicant Date
I & a
Owner or aulloorixed agent All roof coverings to be Class "B" or better
0,
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
afTYOF Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
-700 OSD 'FO /Qe
OWNER'S NAME: PHONE # L10K-37 22,
GENERAL CONTRACTOR: J (v-hW a-f-2 r- Zn L FAX # TD -F
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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 �- ( J�F� r- C� 2 13
Roofing
Septic Tank
Sheet Metal
Sheet Rock
AW Tile
2-!?
—0,5—
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Zo —or (69 q zalos—
Building Address:
-7 1,,7 0-7
Owner's Name: Phone #:
0— �f ?- 373 — YZZ
Contractor: �. Phone: License#:
#01 11/ to- hl C'. Gso - &0/- es'q-4 `1&3(�/�—
Contact: / Phone: Cupertino Business License#:
CAres 4P ces 6,50-03 �2/
Building Permit Info: /
BldgElC9
Elect ' Plumb 2 Mech Cl
Job Description:
s ee_ ��fer gea ier �s 1-r P f-o Ey+er,or'
Residential Commercial ❑
Cost of Project: 4150c)
Strapped On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMPI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
i