03090085 1 CITY OF CUPERTINO
BUILDING DIVIs1ON PERMIT
CONTRAC_"TnRsINFORMATION`. '.
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT NO
250 222TIVAL 1:)R
OWNER'S NAME: 170 BRANNON DR PERMIT LSSUE DATE
)NE' (510) 376-4816 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION O O
E u C 1 hereby affirm that I am licensed untie provisions of Chapter 9(commencing Job Description
Zry with Section](1(N))uf Division3of Nca dProfessinns Code.and my license is
>r'�in Licenlse°c�r.6x�d f` 6yli Lie.x° x799840 REPLACE WATER HEATER
;res Dam Cunrraft O 076 a2 Q I
f 'y As.h.11 CTSDs,obl RAT.ON
u 1 understand my plans shall W used as public meordx
Liccnttd Pmfcssianal
-O,g DWNERBDILDER DECLARATION /
<S I hereby affirm that I am exempt rrum de Contractors License Law for the
p O following mason.(Section 7131.5,Business and Professions Code:Any city or county
s m 'which requires a permit to construct,alter,improve,demolish,or repair any structure ,
-ZY prior to its issuance.alsomqulres the applicant(orsuch permit to rile a.signed statement
a4o that he is licensed pursu ratoumpmvisimu(iftheContractor'sLicense LawChapter 9 Sq. FL Floor Area Valuation
`t-$ (commencing wi N Section 7")of Division 3 of the Business and Professions Cout)to
— the he u exempt Nertffom and Ue basis for Nc alleged exemption.Any violation of 36215030 . 00
Section 7031.5 by any applicant for a permit subjcm he applicant to a civil penalty Of .APN Number act more Nan five hundred dellal.($500). - -- - - -- _.-. Occupancy Type
1,As owner of the property,or my employees with wages as their vole compensation,
will do the work,and the structure is not intended or offered forsale(So,.7Ma,Business „[� �yT
and Professions Code:The.0°mmqora License law docs not apply to an owner of ICC fCQ ections
propenywho Wildsorimprovrs Ncreon,and Lice tlocxucnwerk himulforNrougn his 202 - UNDERFLOOR PL BING
own employes.prodded Nmsuch imprawmenrare not intended orortered mrsale.It' 301. — ROUGH PLUMBING
however.fie building or improvement is sold within mm year of completion,the Owner-
builder will have the burden of proving Nat he did not Wild or impmvc fur purpose of
sale.). 302 - TUB & OR SHOWER
502 - FINAL PLUMBING ENERGY
❑1,as owner of the property,am exclusively contractingmeswith i The
contractors m _
continua Nece notpplyincct(See 0 ,Business andnownerorprop Pywho Wilds ns Code:)
orpm Co themons Li 506 — GAS TEST
rhos Law doesr such Forman nth aommenrs Lice sedprrlmpto Onethcmrctor's 507 - FINAL PLUMBING
who
nse Lacu for such projects with a convactorts)licensed pursuant to the Contractor's
License Law. '
❑I am exempt under Sec. ,B&PC for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby.1 ion under penalty of perjury one Of Ne fallowing declaration:
1 have and will maintain a Ccoifcmc of Consent o set&insum for Worker's Compen-
sation. _
az provided for by Section 37W of the labor Code,for the performance Of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
37W of Ne labor Code,for the performance of the work forwhich this permit is issued. -
/My Worke(r's Compensation Inmacc ntt rirtum
canner a p Pyljvybe,am:'
./Or:J/C:til [ f 111 Policy No.;
UUUIII CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or less.)(This union head not W completed if the permit is for one hundred dollars(SI far)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any Penson in any mam r.maste Wcome subject to the Workers Compensation
Laws of California.Date
Argument
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compmvution previsions of the Latour Code,you must
,Z fonhwi06 comply with such pmviainns of this permit shall W deemed revoked,
Z'O CONSTRUCTION LENDING AGENCY
Zi 1 herchy aRrm Nat there is a construction lending agency for the perfurmanec of
Z> the work for which this permit is issued(Sec.3W7.Civ,C.)
1 Lancer's Name
z lender's Add.
J C) I certify that 1 have need Nis applicmion and sate that the AWvr information is
y H correct.I agree m comply with all city and county ordinances and sure laws relating to
�U building construction.and herchy authons,representatives of this city to enter upon the
N W shove-mentioned property for iasprcdon purposes.
6. (We)agree he mac,indemnify and kap harmlm the City or Cupcnino against (/"_�J K/V
N liabiliticsjudgmcnts.cosuand expenses which may in any way accmc against said City
J z in consequence of the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ACC3M POINT Issued by: Date
SOURC�EG,ULATIONS. _
Re-roofs
store of ApplreanuComxcrur Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nc applicant m future building occupant smlc or handle hanardous martial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.DYe.xss3z(a)] t�kNp All roofs shall be inspected prior to any roofing material being installed.
Will free applicant of future building ecce ant user If a roof is installed without first obtaining an inspection, I agree to remove
it hvardnus air eonmminanu u defined h Nc Ba Area equipment or devices which g
nrmn r Y Quality Management all new materials for inspection.
0 Yes O&Nu
1 have mad the havardous materials reyuirementa under Chapter 6.95 of Ne Cartoon,
ria Health&Safety Code.Scerms¢25505,25533 and 2553x.l understand that if the,Wilding
docs not cunchey Mm a moot Nat it is my respouihility m notify de ax t of Nr
ecyuiremc� high muar c etp' r r issuance ora Cerourare of Occup cy.
9-/,F-v3 Signa[ureofApplicant Date
Local
or authorized agent Da1C All roof coverings to be Class "B”or better
03o,° og �
CITY OF CUPERTINO
OWATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN #
36z-
Building Address: /
Owner's N me: Pon #:
o V 7zS- S
Contractor: Phone: d D Liqgnse #:
Contact P ne: Cupertino Business License#:
b� / w -90 p
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped 00 Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A le Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2--
�K. 61