03080146 'CITY OF CUPERTINO osr+ ks �aq t
PERMIT CON0%1NP,TT2ACTI *TION:3
BUILDING DIVISION
BUILDING ADDRESS: HOTN WATER INC PERMIT Nil.03080146
t
OWNERTS E: 2531 GRACELAND AVE PERMIT ISSUE DAZE
12
NE' (650) 298-8494 SANITARY O 01,NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
181 hereby Affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 100j)of Division 3.r the Business said Professions Code,and my license is
in full fuel and ec
;p� LieeOsecitisd Gt'' It- Lie.. � (VQREPLACE WATER HEATER
ftp Dau U camanor � -
ARCHITECTSDECLARA ON
I 1 undersand my plans mall he used as public menrW
O Licensed Professional
OWNER-BUILDER DECLARATION
<X I hereby affirm that I wo exempt from tW Comremors License law far IW
OO following moon.(Second 7031.5,Business and Profession Code:Any city or County
< which rcquiro a permit to construct.alrec improve,demolish,or repair any swauic
uZi print m its ioua.nehu requirestMepplieant far such permit to file satg.d,uument
< Mat he is licensed Possums 1.the Provisions nfih.Co.,...Lt...Law(Charter 9 Sq. Ft. Floor Area Valuatio
r�-$ (commencing with Section 10)0)of Division 3 of the flumes and ProfessionsCade)of
`t that he is exempt themrrom and the hasu for la alleged exemption.Any vialauon of
Section 1031.5 by any applicator for a permiuubjecu the applicant to a civil penalty of APN NumberOccupancy Type
not more than five hundred dollars($500).
❑I,as owner of the pmpmy,or my employees wish wages u their sole compermadon.
will do the wont and the suramare is not intended or offered for said(Sao.1064,Business 502 - FINAL ff1Lh $TaFtcffaERGY
And Profession Cade:The,ConuacmYs Lt..Law does not apply in an own,of
property who buildsor Improves thcmon,and whodas such work himulfor through his 506 - GAS TES
own employees,provided that such improvements see not intended moRered fortale.If. SO7 — FINAL PLUMBING
however.the Wilding or Improvement is mid within one yea or compkoon,Ne owner-
builder will bate she burden of proving that he did not build or improve far purpwe Of
ale.).
❑1.as Owner of to property,am c rcluainly amuse ing with licensed Contractors to
cense La desne not (See.1044,Business and Profession ds or h rpro Common's id EXP i.
cede hw docs noupplr e ts owner of propersy who Wilds of improve Conran,andwho convacu fanech projects with a conlrumr(e)lia.ed purtuam m to CanuumM1LicenseeexeLAW
❑I em accept under Sec. .B k P C for this moon
Owner Dau
_ WORKER'S COMPENSATION DECLARATION """'�-
1 heuby alarm under penalty of perjury one of Ne following declarations: EDi
I ban and will maintain a Cenifase of Consent to self-osum rot WorkersCmnpcn-
tian.m provided for by Section 3100 of the I�Wr Code,for the performance of the -
work for which this permit is issued.
have and will maintain Workeh Compensation Insurance,o mquired by Section
3 170 of Ne labor Cod.,for the performance of Ne wok for which this permit is Issued.
My Worker's ompensmon Insu^race carrier and Policy numb&
Cartier. { IQ' t`V Poliry No.: l{1 _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbuctim need no lbecompleud If the permit is know hundred dollars($I01)
err I.a)
1 certify that in the perftmance of the work far which this permit Is issued,I shall not
employ any Nixon in any manner xo As or become subject to she Workeri Compensalion
Laws of California.Dam
Applicml
NOTICE TO APPLICANT:IL after making this CcMacete of Exemption,you should
become subject to the Workers Comp.narion provisions of the Labor Code,you muss
� Q foMwidt comply with such provisions or this permit shell Ise deemed linked.
ti tiCONSTRUCTION LENDING AGENCY
1 h..hy affirm Met tare its consumed..lending agency far the Parr armen.of
x> the work for which this permit Is issued(Sec.3091.Civ.C.)
YQ Lendcr'a Name
z Load.,&Address
;)Q I certify,that I have mad this application and sou that the&hove information is
y t" coned 1 agree to comply with all city and county ordinances Of and sou laws reining to
C.) 41howngconswetiro entl arebyacininp representatives of this city to tour upon she
aWve-me e)nodagree
to property for emnify An proposes.
r y (We)agme to an.indemnify and keep hay in ala City of Cupertino Against
rat incoisequenc of the
expenses which may In any way accrue against aid City
J 7 A APPLICANT
of the RSTA GOf this permit �ko_
r7- SOURCANI'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date —03
SOURCE REGU�TJ �
''))II Re-roofs
Signature of ApphantContrut a Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding Occupant nom or handle huardoa material
o defined by Be,Cupentno Municipal Code.Chapter 9.11.and the Health and Safety
Code.Sean.25531431 All roofs shall be inspected prior to any roofing material being installed.
❑Yat ❑Nu
Will the applicant or future Wilding Occupant use,equipment m nevi,"which If a roof is installed without first obtaining an inspection,I agree to remove
It wloudous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
6aKR
Yes ON.
I have read the hmarthms mauriats mquircmenu mok,Caput 6.95 or Ne Calif.,.
nix HOW h SafmyCodc,Scenic.25515,15533 and 25334.1 makda rad Ihu if the Wilding
it.not Carmntly ban a seat.the it u my responsibility u notify the occupant of she
mtlutmmrt!Jh(t/9a!s to met jPrior nloaneeofacedrieate.roc an �a3 Signature of Applicant Date
ownera„am�ieJ agent — Dom— All roof coverings to be Class"B"or better
CITY OF CUPERTINO o 3 o �6
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# (] 8 Date:
Building Address:
d2l� �2r� 6, Aiw&i Oc/AG€ Gl
Owner's Name: Phone
Contractor: hone• Licen e#:
�Lel 2f� ���9'f � 3(9/ Z
Contact: Phon Cupertino Business License #:
C14k LlI-A ,JZ
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: / 1
Residential Commercial ❑
Cost of Project:
• Strapped ❑ On Platform ❑ Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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