04010094 FTry OF CUPEwrINO d'+"" "'= *� .ol
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION , -
B.DIN'GADDRESS: WATER HEATERS ONLY PERMIT NO04010094
NER'S NAME: PERMIT ISSUE DATE
Q'I
ONE: SANITARY N0. COhTitOL NO.
(BQQ) 835=994C
ARCHIMCT/ENGINEER: BUILDING PERMIT INFO
BLDC ELECT PLUMB MECH
0 0 0 0
.0, LICENSED CONTRACTOR'S DECLARATION Job Description
2.5
C 1 hereby affirm that 1 am liamcd under previsions of Charrter 9(commencing
Szel with S.Comn70(k).f Divid.m3ofdre Businen ngprnfy�i M ndmy lice c IN®L�®
^jy iicensemeander(e�t..;(� SI__II t EPLACE WATER HEATER n"a
ea z License el =>/ sac _
�— Dae FEB 't ,t
ARCHITE S DECLARATION EB 1 2 2004
C 1 understand or,plans shall he used as public recons
JaU
;aLicensed Professional
G5 OWNER BUILDER DECLARATION BUILDING
'a 1 hereby affirm that 1 am exempt from the CmdmmOrs License Law for the
00 fallowing moon.(Section 7031.5.Business and Pmfesmons Code:Any City or county
K m which requires a permit in consumer,alcor.improw,demolish,or repair any structure
Lai pdnnn is issuance.alsn¢quires the applicant forsuch permit to file a signed statement
< that he is licensed pursuanothepmvisionsoftheContractoriLicenseLaw(Chapter0 Sq. Ft. Floor Area Valuation
pursuant
yFD (commencing with Section 700M of Division 3 oohs B usiness and Professions Cnle)or
y $
that he is exempt therefrom and de bum for for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a .is subjects the app CVC to a Civil pc why of 32%T4;.13'blB*crp pOccupancy Type
not mom than fin hundred dollars(S50(f.
❑1,as owner of the property,or my employees with wages u their sole compensation,
will do the work,and the suumum is nut intended or offered for sale(See.7044.Business
and Professions Code:The Contractor's License Law does nor apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself orthrougb his
own employees,provided that such improvements are not intended oroRered forame.IL
however.the building or improvement is sold within one year of completion,the owner-
Wilder will haw the burden of proving that he did not build or improve for purpose of
.1e.).
❑I.asr of the ppeny.am exclusively contracting with licensed contractors to
Construct the mproject(Sec.7044.Business and Professions Code:)The Contractor's Li.
cense law docs not apply to an owner of property who Wilds or improves themon,and
who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's
License Law.
I nm exempt under Sec. .B&P C for Nis mown
mor Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a CeniOt
c o of Consent to selGinsum for Worker'sCmmpen-
amion,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
3700 of the Laber Code,for the performance of the work for which this permit is issued. -
My Workers Cn s lesunce ncarrier and Polity rourri sr ante C`''
Carrier: t' PolieyNr.: Rn 85tLZ3
IFICATE OF EXEMP
CERTIFICATE FROM WORKERS'
COMPENSATION INSURANCE
mus section wed net he compleud if the Trrmit is for orc hundred dollars(SIOV)
kat.)
I certify that in the performance of me work for which this permit is issued.1 shall nut
employ any person in any manner sin u to become subject o the Wmkera Comlrrnation
Laws of California.Dar
Applicant
NOTICE TO APPLICANT:If,after making this Cerolimm of Exemption,you should
become subject to the worker's Compemntion previsions of the Labor Code,you mum
�2, forthwith comply with such provisions or this permit shall he Mcmcd mvmkcd.
ZO CONSTRUCTION LENDING AGENCY
l" I herchy al arm that mem its comtructinn lending agency lot the Performance or
cede work for which this permit is issued(See.30W7,Ci,C.)
W Q Lendcr's Name
Lender's Address
D z
U Q 1 certify that 1 have mad this application and stoic that the aWye information is
" F-' correct.1 agree to comply wire all city and county ordinances and sum laws relating to
0 U Wilding Conswction.and hereby mohorim mprexmaiws of this city to corer upon the
1
mervc-menfioned property for inspection pWo
fus.
(We)egret to saw,indemnify and temp harmless the City of Cupertino against
F' rq liabilities,jud6 s,toss an expo mhich ma -n any way acerae against said City
U z in C. ruse life is r t.
^ APPL N ALL NON-POINT Issued by: Dale
SOURC REO LA 1 a�_/e
�y/ Re-roofs
Signawrc of ApPli<anVComracmr am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store orand a Hcalm and
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safny
e,Semien 25532(.)?
Oyes ON. All roofs shall be inspected prior to any roofing material being Installed.
Will 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
7ni.
hazardous at r contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
notes?
❑Yes 0 N
I ban real the havamous materials raquimments under Chaplerri95 oflhe Califor
alm&SafetyCole,SeNons 255(15,25x33 and 25534.1 undersand tht,fthe Wilding
not currently hove a tenant,that in is my responsibility to nodly the OCCUPant Of the
imoo;w' h must be mel pau issuans ar accmncate of Deem aney Signature of Applicant Date
a I D
owner onto All roof coverings to be Class"B" or better
CITY OF CUPERTINO
4 WATER HEATER o ( c> ,)
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: /(0 �3
Owner's Nam Phone#:
glu
Contractor: � O License3
#: 3 S�5 7
Contact: � Phones
C O-Q) $35 - Sgv (.
Applicand6eatiaetor:
• 1� /3- 4"'t �51 o) S y —/23 -Z--
Building
Building Permit Info:
Bldg Elect lamb) Mech
Job Description:
esidential �GrJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
� Sa
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
/ BENERGY Ener BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE PlumbingPermit Issuance PLUMBING
BPERMFEE BldgPermit Fees BUILIDNG
BMITIGAT HousingMitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG