05120133 CITY OF CUPERTINO ao-ys«rgv«. �.
BUILDING.DIVISION, PERMIT ,ION1 !�+, � � 4 . AT
B[RLDING ADDRESS: CALIFORNIA WATER HEATERS & PERMIT N005120133
'OWNER'S NAME: PERMIT ISSUE DATE
ICANNIS KANELLAKOPOULOS
NE: SANITARY NO. CONTROL NO,
650 558-1575
ARCHiTER/ENGINEER: BUILDING PERMIT INFO
BQ EO PLO MECH
O
�o o LICENSED CONTRACTORS under D pecOudons f Chap lob Description _
rd ION
1 Mroby affirm that I am licenseof
Bu i under and
Profs of Coder 9(commencing P
with Section 7810)of Diviilon las the Buaineuan0 ProfeWanx Code and my license is
n
in full adetf ® REPLACE WATER HEATER
Z_ Licemc Class TSD _
Dam used as public
—_—'ARCHITECTS DECLA IO
I undcssund my plana shall he used u puhlic rtcor& J
,6u ��G Licensed Professional
py3 OWNER-BUILDER DECLARATION
9 a I h ..(firm that I am exempt(mm the Contractors License Law for the IR&W /
C O O following.won.(Scotian 7(B 13,Business and Professions Cade:My city or county n^
$ri which requires a permit to coutroct.eller,bnpmw,demolish,or minor any stmctum '1// 3 5 0
—�y prior m its his.... so re
o=e.slquims dteapplieant for such permm it Bleeslgned smmmcnt
�< that he u su
licensed purant to the proviswnsofthe Contractor's Ucense U.(Chapter 9 Sq.Ft. Floor Area �' Valuation
(commencing with Section 700B)of Division 3 of the Burinm and Professions Code)on
�.. dost W is exempt memfrom and IN basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit mbjecu de applicant, ..ivil Penalty ofcm3 Type
oat mom than fin hundred dolls(5500). •7
❑1,u everter of the property,m my wploym with w ges u deb mle mmpemadon,
Mlldo thewmk.mdthegm m[snoonmM waneredfomm(Sm.70u,Butircss Required Inspections
and Professions Code:The Commerce,Lime law dm roet apply to an owner of q P
property who bWlds m improves Nemon.and who does such work himself orthrough his
own employma.pmvidcd that inch Imprewmenu sm not uncooked moruW ferule.if.
howewr.the building or improvement is sold within aro you of compicumn.the owner- ,
builder will haw the Women of pouring that he did Out build m improve for purpose of
umJ.
0 1.u owns of the property am exclusively contracting with licensed conessons In
consumer the project(Sec.7044.Business and Prefesdam Code:)The Conuamoh U.
came law dm rot apply to an owner of propeny.who buil&or Winnows thereon.and,
who comoscu me such pmjem with aconrs-mrtU licensed Merman to the ContrxmYs
License Law.
❑l am exempt undo See. ,B d P C for this ream"
0.— Dam
WORKERS COMPENSATION DECLARATION
1 hereby&film under penalty of perjury one close following dmlaruiora
1 howcab will.maul.•CerdficamorCome tmaelf4es.mewmimescompen-
1C371.1
on,or provided for by Section 3700 of the labor Came,fm the performance of me
k for which this permit u issued.
1 haw and will maintain Workeh Compema0on Inmra e,as required by Section
0 of Ne labor Code,for do performance of the work(or which this permit is head.
Worleces Compensation In.carrier and Poli,number are:
rrier.��J/�'//eje Poli,No.:
CERIIFaAA OF�EKEMPPIONFROMWORKERS'
COMPENSATION INSURANCE
CThu=MM need rot be completed If tie Permit Is two=hundied dollar&(5100)
or mss)
I«nify Net in me performance of the work for which this Permit It issued.I shall not
employ anyperson in my mance become 'no thewo Compensation
Laws of California.D •a � 'I i
Applicant �a--y�
N077CE rO APF AST. f-afwr mATHTihm Ctmficae of Exemption,you should
become subject to me Worker's Compenution provisions of me Labor Code,you muss
vJ O forthwith comply with such previsions Or this permit shall bo denmcd mated.
r0 CONSTRUCTION LENDING AGENCY
H 1 hereby alliin that then is.commuctinn lending agency for the performance of
D:v> time work(or which this permit is head(Sm.3097,Civ.C.)
6Wi Q Lendst's Name
z Lender's Address
()Q i certify that l Mw not this application and sum ren the show informals b
F coma 1&goes on comply with tl1 city and county ordinances and sum laws relating to
QU building convection,and hereby sumorise repreaeaoslim of this city to enter upon the
ISl ahow-mentioned property for inspection purposes.
(We)agree to caw,indemnify and kap harmless the City of Cupertino against
IA Ilabili0o,judgments.costs and expenses which may In any My acme against said City
C) in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI
Re-roofs
Signature of ApplicandComrmrer Dam-
HAZARDOUSMATERIALSDISCLOSURE Type of Roof ,
Will the applicant or future building mcupantsmm or handle huardoms material
as dere=d by the Cupertino Municipal Cade.Chapter 9.13.and the Health and Safety
Calc,Section 35532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑You (�Fo/
Idow,
wiill the applicant or/Ytnuun ulldinp Occupant use equipment or dcvicu whichIf a roof is installed without first obtaining an inspection,I agree to remove
It haverdoas air conuminanu u deem a Bay Ana Air Quality Management all new materials for inspection.
micR❑YesI have mad de hoard=s materials requimmcnu underchapter6.95ofine Califon Hulse&Safe yCode,Sections 255)5,25533 and 25534.1 undendand thatifdm building
not currently how a&nam,mat it is my responsibility m nalry me Occupant of dw
ulmmenuwhm ustWm pdorwiuuweofaCcNrcamofOccyparmy. Signature of Applicant Date
0er uriuthorimd agent Data All roof coverings to be Class"B"or better
�
CITY OF CUPERTINO 0510qp►33
WATER HEATER
II OF
CUPEPTINO PERMIT APPLICATION FORM
APN# Da
Building Address: rip 2d "��
lF.r.C�T
Owner's Name: Phone#:
Mr., _ 7
Contractor: Phone: License#:
is erre la��-v�'L� 4�1�
Contact: 44!pi G/JG,/,� W:5- Phone: Cu ertmo Business License#:Building Permit Info:
Bldg ❑ Elect 62, Plumb Cam Mech (�
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On Platform Bonded
• New Location ElReplacement 0
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING