03070093 ' CITY OF CUPERTINO =:'
BUILDING DIVISION PERMIT CON TRACTORiINFORMATION*"
BUILDING ADDRESS: WELKIN INTERNATIONAL IND I FCgMITND03070093
OWNER'S NAQIITRR P;
ME: 19925 STEVENS CREEK BLVD PERMIT ISSUE DATE
ONE: (408) 252-3396 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_oo LICENSED CONTRACTOR'S DECLARATION O O O O
x C 1 hereby.firm that l am licensed under provisions of Chapter 9(commencing lob Description �� is 9 [[
e¢W withSmion 70710)of Division 3of Ne Business sins and Professions Coe.and dmy license is aE0
in full forte and effect.
o2 License Class Lie.. WATER HEATER REPLACEMENT
F
Dam Contractor AUG 0 5 2003
ARCHITECTS DECLARATION
1 underaland my 1...h.11 be used as Public recut&
;0 Licensed Professional BUILDING
OWNER-BUILDER DECLARATION
<$ 1 WMhy affirm that 1 son exempt from Ne Contractor's License Law for the
000 following reason.(Section 703 1.5,Business and Prefesdons Code:Any city or county
x m Y. which reyuires a Permit In construct,alter,improve,demolish,or repair any s aclum
ca v" poor e)in issuance,also requires the applicant for such Permit u Glc a signedstatement
Eo that he is licensed pursuant to the Provisions or the ContractorsLiecuseLaw(Chapter 9 Sq. Ft. Floor Area Valuation
a� (commencing with Section 7000)of Division 3 of the Business and Professions Codc)"or
a. that he is exempt therefrom and 0e basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars(SSW).
0 1,as Owner of the pmpxrt,or my employees with wages as their sole compensation,
will do Ne work and the swctue is not amended or offered for sale(See1061,Business 502 - FINAL lFthMiaFtell�NFRGY
and Pmressipm Code:The Cmursel rs License law does not apply a an owner of
papeny who builds or improves thircon,and who doesmehwmk himulror through his 506 - GAS TES
Own employees.provided that such improvements are,not intended or offered fmsale.If, 507 — FINAL PLUMBING
however.N
e building of improvement is sold within one you of completion.the owner.
builder will have the burden of proving that M did not Wild or improve for purpose of
iala).
h as owner of the progeny,am exclusively competing with licensed contractors to
co swcl the project(Sec.7064,Business and Professions Code:)The Conmemr's Li.
cost law does not apply to an owner of progeny who builds or improves themon,and -
who comrace rid inch projec%with a contractor(&)licensed pursuant the Contractor's
License Law.
0 1 am exe(pt�,t,2nd c. _ ,B& C ro his reason
Ow VI/1 Data
(J \'00.1 R'S COI1NSATIO RATIO
1 hereby am.under penalty of perjury oro of 1 in I atom:
I ban and will maintain a Cor ifinte ofConunt to selr-insum for Worker's Compcn-
sation,as Provided for by Section 31W of the laWr Code,for the performance of the
work for which this Permit is issued.
0 1 haw and will maintain Worker's Compensation Insurance,as"stied by Section
37W of the Labor Code.for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance earriar and Policy nunsher am:
Career: Pol icy No.: _
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
less.)(This section need not becomPlcled if the Permit is for one hundred dollars(SI W)
n
1 certify,that in the performance of the work for which this Permit is issued,I shall not
emPloy any Person in any manner so as m become subjecuo the Workers Compemation
Lam of California.Date
Applicant
NOTICE TO APPLICANT:If,after making Nu Cenificae of Exemption,you should
become subject 10 the Worker's Compemation provisions of Le labor Code,you most
.,O fordwith comply with such provisions or this permil shall W deemed revoked.
z y CONSTRUCTION LENDING AGENCY
F I hereby affirm that there is a construction lending agency lm the performance of
(� the work for which this permil is issued(Sec.3(197,Civ.C.)
aQ Lenders Name
a Lender's Address
0 Q 1 cenify Nu 1 have read this application and state that the above enter upon is
ty F select.1 agree IP comply with all city and county mminmees cad sum laws rclaling to
QU a1mve-geotioned roend herIn,by poputhoriprposes. olives of NisCity mcnmrupon the
ahovomemioncd Progeny for iexpeNon which may
tom„CL Dw)agree to save,indemnify and keep harmless the City of Cupertino against
h liebililies,judgmena.costs and expenses which may in any way accrue against aid City
V z in consequencbry¢ming of this Permit.
APPuse A STANDS AN ILL COMPLY WITH ALL ON-PAINT Issued by: Date
Signa p p eanl/Contr er TOU Re-roofs
Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(cure building-consul store or handle hazardous material
as defined by the Cupeni no Municipal Code,Chapter 9.12,and the Hml lh and Safely
CoJc,Section 25532(¢)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya&
will the appbaanl nr ratnre beBain occupant as a If a roof is installed without first obtainin an ins ection,I agree to remove
g pan quipment Or devices which g P
it hoeardnus air cnneminamx as defined by the Bay Arca Air Quality Management all new materials for inspection.
isuict?
OYcs �Nu
I have mW the harardiwsmaerials requirements under Chaper695oftheCalifnr-
niaHealut&SafnyCoda. sedum255115.25533 and 25531.1 undersand that tfrae Wilding
does or currently In lenm4 el a retpenxlblllly 10 nndl)'the MYupml Of Ne
uquire rdhw tae Tr. or riss or.r.censWc,
Signature of Applicant Dale
Dwn et ed.gc D,e All roof coverings to be Class"B"or better
CITY OF CUPERTINO o 3 o v q 2
-- WATER HEATER 7
• CUPERTINO PERMIT APPLICATION FORM
APN # y f� �Z r ?p Date:
Building Address: V (n
05 v
Owner's U , )� G \� n Phone#:
C r: - Phone: 03 —7 License#:
Qa n 7nfs 011
Cont (26k Phone: Cupertino Business License#:
1xPn
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descriptiio :�er HeA* re ' gcemen f
Residential Commercial
Cost of Project:
i1 ,
• Strapped ❑ On Platform B nded El
New Location ElRep'
ace e
Qt . ,
lica le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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