03100073 CITY OF CUPERTINOmaNI
BUILDING DIVISION PERMIT CONTRACTORtIORMAyTTI�"Q'Nsi
"
BUI LDING ADDRESS: HOTS WATER INC PERMITNO.03100073
owNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
JNE: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
o o LICENSED CONTRACTOR'S DECLARATION
i C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
�Ybw with Section]IXX))nf DivisionJo(Ihc Busincu and Professions Code,and myliccn¢is
infullfrom ciass, cff� T 31 WATER HEATER REPLACEMENT
s g License tau `l Lic.M
DaIC ��)_ GUllleaebr
ARCHITECTS DECLARATION
i I understand my plans shall he used As;public recnNs
5y0
'0.tn Licensed Prnfcssinnal
1 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt(rum the Contractors License Law for the
e O O following mason.(Section 7031.5,Business and Pmfeasioes Code:Any city or county
S$ which requires a permit to consuum,slim,improve,demolish,or repair any structure
prior in its issuance.also requires the applicant for such permit to fin a signed statement
i C that he islimnsed pursuant to the provisinmof Ne Commcuo'a License LA.(Chapter 9 Sq. Ft. F 00 fed Valuation
i $ (commencing with Section 7(1 of Division 3 of the Business and Professions Cone)or
] — Not he is eaempl therefrom and the 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 A Nilmber Occupancy Type
not more Nen five hundred dollars IS500).
1,as owner of the property.or my employees with wages as their sole compensation,
will do the work.and lhestructure is not intended or offered for sale(See.T ,business " rN�LiI (lp4K4 GY
and Professions Code:The Contractor's License law docs not apply Ir an owner of
pmMny who builds or Millions thereon,and who does such wmkhimselfor through his 506 - Af6��/TJES•
awn employees,provided that such improvements are not intended Orobcred for sam.If. SO7 — FI7LliLl PLUMBING '
however.the building or improvement is sold within one year of completion.the Mines. V
builder will have the burden of proving that he did not Wild or improve for purpose or
Asia.).
❑I,as owner of the property,em exclusively contracting with Iicamad contractors to
construct the project(Sec.7044,Business and Professions Com:)The Contractor's Li.
came law does not apply to an owner of property who se.itis or improves thereon.and
who mmraw. projects such projeewith aconuuumm
tar(s)licensed resonant Contractors
License law.
❑lam exempt under Sec. ,B&PCfor this moon /
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlly Of perjury oro of the following dmlarstions:
1 ban and will maintain a Certificate of Consent to self-insum for Worker's Compere
As ian.As provided for by Section 37W of the labor Code,for the perfomanee of the
work for which this permit is issued.
an and will maintain Wankel.Compensation Insurance,u required by Section
]OO Of NC labor Code,for the performmce of the walk for which Nis permit is issued.
My WarkefA Com pemAmioTn Insurance carrier and Policy number sure-
Came
rt:
Camcr._ 5,/ 00, PolicyNo.: /sIF 3�
CERTIFICATE OF EXEMPTION FROM W ORKERsc
COMPENSATION INSURANCE
(Thissemim mail nm he completed if the peril b for arc hundred dollars(5100)
nr Ices.)
1 certify that in the ar l rmance of the work for which this permit is issued,I shall not
employ any person in any mannersn As in become subject o the Worker.Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.After making this Certificate of Exemption,you should
become Subject to the WOekn.Compensation provisions of Lou LAW,Code,you must
OroMwith comply with such provisions or this permit shall be rimmed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conswnion lending agency for the performance or
Y.> the work for which this pnmit is iasucd(Sec.3097,Civ.C.)
YQ Lender's Name
5 Z Lender.Add.
Q 1 mnify Nu I ban mad Ni,application and state that the above information is
y P correct.I agree to comply with JI city and county ordinances and state laws misting m
�U building convection,and hereby authorine moatentmivm or this city to enter upon the
a above-mentioned property,for inspection purposes.
(We)agree to save,indcmni fy and keep harm leu the City Of Cuxm,dlm against
N liabilities,judgmcnU.costs and expenses which may in any way aunc against Ali dCity
J Z in comecterm of the 6nummg of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE UL NS. µ-lC.-./ 10/6
Re-roofs
Signature o ApplicanUConlnctor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant stare or handle hazardous material
C"
defined by Ile Cupertino Municipal Colic.Chapter 9.12,mJ Be Hcaldl and Safety
ffilCm,`ZcIi..255329r! ,MNa All roofs shall be inspected prior to any roofing material being installed.
❑Yes
WiII the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvardnus Mir contamim ds u divined by the Bay Area Air Quality Management all new materials for inspection.
iibicl?
E]Yes I�avu
1 have mad the hmaNnus maerials requirements under Chaper6.95 Of the Califon
nia Beath&Ssibty Curie,Sections 25505,25533 end 25534.1 understand that if the building
does not currently have a mnam,that it is my respomihility,w notify the aecomon of the
reyuiremc hick MU Lto tpriurw ivuancc ora Certifies¢a(Occu Signature Of Applicant Date
- =`��E' �e"' All roof coverings to be Class"B"or better
Owner or in mired agent note
CITY OF CUPERTINO
WATER HEATER
• CUPEII;TINO PERMIT APPLICATION FORM
APN,# l� Date: l 6 63
Building Address:
Owner's Name: Pho :
� � ��'miYifliZ Z--/Lb J 3
Contractor: Phon • License#:
C_J
Contact: one: Cupertino Business License#:
bas 14"w 6
Building Permit Info:
Bldg ❑ Elect ❑ Plumblrih Mech ❑
Job Description: `Nlq/
Residential Commercial ❑
Cost of Project:
• Strapped El On Platform L1 Bonded El
New Location ❑ Re lacement-�p
Qt i ,r
A ca le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING