03070050 ( CITY OF CUPERTINO
BUILDING DIVISIONPERMIT &CONTRACTOR INVORMATION.
BUILDING ADDRESS: PERMIT NO..03070050
• OWNER'S NAME: PERMIT ISSUE DAM
;NE: SANITARY N0, CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o
B o o LICENSED CONTRACTOR'S p DECLARATION
li I ionhy affirm that 1 t 3 licensed under provisions orChapter9(commencing Job Description
z with Section 7tlfal7 of Diviaion3ofw Bueinas and Pmfcoi ms dc.and mylicense b
in full Armand of L
q� Uan:< 3 (o Lic.N INSTALL WATER HEATER (100 GALLON)
-- Dare c.ntn.mr CONTRACTOR: WATER HEATER & PLUMBING EXPERTS
ARCHITECTS OEC ON
I understand my plena shill he used asp cords
C
Licensed Professional
qy S Oat I..exempt
from
DECLARATION
4 M O I hereby,(Sero Nn I am exempt from w Contras Co License law for the
p0 which following nnenn.(Section t IDSLr Business and improve,
d,roli Code:Any city.,cony
which Cots iresissu a permit m tont the applicant
improve,h remit t ter mryig any t temum
ZT prionniuiensed pursuant
the thecvisions of for such remit to fikaeLaw(utemrnl
o that heidle,nwJpSectiottntheofDivision3 rtheBuamssandReclawlCode)or Sq.Ft. Floor Area Valuat 950
(comm,at
I, xicrett dienion70W)nf Dlvrionr uCalleueinexempton.Any
Code)of
— Net he ie exempt any aom and the beer for be cts th tl exemption.Any violation of
not omthLSby veaundredicantfonpermhsubjectsNcepplicmtloarnllpenaltyof 3MN�g2ter00 Occupancy Type
not mom than Rro hundred dollars(1$00).
I,o owner of the progeny,in my employer with wages as their tole Compensation,
will da the work and w swnvre is not intended or offend for sale(Sec.7Mp Bueines.
and Profession,Code:The Cnnlnctor'e Limon Law dote nm apply to an net of Required Inspections
property who builds.,improv thereon,aml who doeaeuwork ch himselfor through his 301 - ROUGH PLUMBING
own employces,provided that Such oripowepronds,re not intended oroffeted for sale.If. 303 - ROUGH MECHANICAL
however,the building or improvementon is sold within oyear of completion,the owner
builder will love the burden of proving that he did not Wild of improve for purpose of04 - ROUGH ELECTRICAL
sakJ.
O L as owner of the pepeny,am exclusively contracting with licensed contractors to 150'5 - FINAL ELECTRICAL
construct the project(Sec.7(N4,Business and Professions Code:)The Comomud's Li. 507 Las FINAL PLUMBING
cense Law doge not apply to an owner of pr.peny,who Wilds or improves thereon,and N-9 0 8 �- F NAL MECHANICAL
who contracts for such pmjecu with B comnmor(0 licensad pursuant to w Contractors
LicenseLaw.
❑Ism exempt under Sec. .B At P C for this moon
Owner Date /!
WORKER'S COMPENSATION DECLARATION V •'
1 hereby M.under penalty of perjury oro of the following dr4ariam .
I have and will maintain a Certificate of Consent to self-insum for Worker's Compcn- V
IC-1
on,u provided for by Session 3700 of do labor Crede.far the Performance of the
W
for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,n requined by Session
Oofthe Vneoperafm the performance Capt.and
mentich this permit is issued. ! '
Worker's Compensation Insurance artim and Policy numkr are:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted If the Permit is mrone hundred dollars(SIM)
or ICo)
I eenify that the Cone [c of the work for which this permit r issued.I shell nut
Laws en ranni s fisan rsnumhecomc Cubjceuo the Workcn'Compcnsnion '
Laws of Ca .roue.Det
Appli
NOT E TO A PLICANT:IL a ter mer. Certificate of Exemption,you should
Wcome m the Wmker'a C.17K cion provision,of Nc Labor Coda you must
.J O f sl wi In comply with such provisions or this Permit shall he deemed revoked.
z CONSTRUCTION LENDING AGENCY
ti
(-+ I hereby which
cut[them itacdfSC,.W7.Cing.penry for performance
C' the work for which this permit I.issued(Sec.JU97,Civ,C.7
6W.o Isnder's Poem
u`T. z Lender's Addfcn
V O 1 cenify No 1 have read this application and mu Net the.hove infonnoiun i,
ly F correct.I agree to comply with all city and county ordinances and state laws relating to
p building construction.and hereby auttoon,npresenutiros or Nis city to corer upon the
Uahovnmerimscd pmpeny for inspection purposes.
(WcJ rte to\d""',
and keep harmless Ne City of Cupertino against
y Eabdhiea,j.d encs, iespemee which may in any way scene,agatnn saidCity
t.3 z iensaqucne fthe of Nis permit.T DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
GU T
•N\ rl� !� Re-roofs
nature. PMic.m.eComncmr ate /.Y
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicantm fotun building we.ruct mre.,handle hamdousmound 1'
at defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes C]No
Will the applicant or future building occupant use equipment or devices which If a roof is i tall d without first obtaining an inspection,I agree to remove
tit h.s.dous air conmmina is o defined by the Bay Area Air Quality Management all nl;w ma er als r inspection.
uric.?
0Yet 0N
Ihevcrea ehavatdnusmateddsmquiremcnuundcr Chapwr6.95ofthc Califnr
nip Health,S461y ntl,SeLgons25505,255JJ.nd25534.Iundcnuul thnif Ne Wilding
tiro. i cutsedfy h s a tenant.Nath r my responsihility m notify tW rceupant of Nc
require encs ich ustWmetpfinnnissumccoracenifcallof uany. Ure fApplieant Date.
ter tbnriacd agcnl ,� All roof coverings to be Class "B" or better
CITY OF CUPERTINO
WATER HEATER is
RICUPEkTINO PERMIT APPLICATION FORM
APN# 2 / 2J r Date: 1/8/a 3
Building Address: I
/oz/o Al, Foo-r11iu, 1Rc vp Cv o. :r e CA , sod S!
Owner's Name: Phone#
t yob zss —39s
Contractor: Phone- License#:
y h-e Aldi G (So �3f1/-9 69 R/-z Z/6
Cont ct: P one: Cupertino Business License#:
0 • Cg,�Np/
Building Permit Info:
Bldg ❑ Elect ❑ Plumb.g Mech ❑
Job Description:
/i // -✓SrA /f-c
"GC� /ao � .J G+fa ' ZE$o oaa BTv
Residential ❑ CommercialAa-
Cost of Project: �9� a�
Strapped On Platform El Bonded
New Location ❑ Re lacementz
Qty •f`
AppVcObl Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
Z-2-- /