03100071 CITY OF CUPEI INO = - `
BUILDING DIVISION PERMIT t C.0NTRACT R INFORMATION:M
'OW'
BUILOING ADDRESS: HOT WATER INC PERMIT N0.03100071
OW NER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARC HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
!Op LICENSED CONTRACTOR'S DECLARATION IobDescri [ion
ZI hereby affirm that I am licensed under provisions of Chapter 9(commencing p
< with Section 7000)of Division 3 urine Business and Professions Cade,an dm license is
i 2 in full force and fIv WATER HEATER REPLACEMENT
Lha, 0 Clayyv Llc,p
Dat) Y Contractor t `•�*.
ARCHITECTS DECLAR TION fry
1i
� I undemtanJ my plans shall he used As records
cnrJs
?
exp Licensed Pmfcssional I
OWNER-BUILDER DECLARATION _
y 1 thereby lm.(Sem that I am exempt from dm Commnar'a License Law for the
.t]O
which
nginomn.(S.itt fl13L5.Bu.],ass and improve,
d.rnnsh.to
S$ which reyusca a permit re construct,plea improve,h Permit t of repair any suvnuin L/ l 1
•iy
prior it) issuance,also inquires the applicant for such permitmfileesigneJ stetemem
x< Chat
2 C3 Q wit Pusoam mod) iinm ofthc oeme's Liccnx Law(Chorter9
Sq.Ft. FloorA a ,.. V UatlOn
(commencingth Section ofDvtheBisnessand Professions Cod))Or
that he isempt therefromrom and te basis for the alleged exemption.An
violation of 36232017
Section 7031.5 by any applicant for a permit subjects de applicant m a civil Penalty Of APN Number c" ancy Type
not mom than five hundred dollars(S500). _
1,As owner of the Property,m my employees with wages as Nelr sole compensation. T7]5Ap n
will dole wad,and deswcntm is our intended or offered fouale(Sec.1044,Business — L YPILtlfiEH T4FRcWAWRGY
and Pucha ions Cade:The Conmct.fa License Law does not apply to an owner of TT r�
property who Wildso,improve,dmmin.nd who docasuch work himself.,through his 506 - GAS TES
own employacs,Provided that such improvements are not intended orartered mraale.If, SO7 — FINAL PLUMBING
however,the building or improvement is sold within one ysu of completion,the owner-
builder will have the burden of proving that he did not Wild or improve for pmpox of
sato I
❑1,as owner of Be property,am exclusively committing with licensed contractors to
construct One project(Sec.70x4,Business and Proksaim,COA10 The Coarscud's U.
cense Law does not apply to an owner of property who builds or impross Nemon,and
who contracts for such projects with a canlractor(s)licensed pursuant to the Contncloes
License leve.
❑l am exempt under Sec. B k P C for this,)axon
Owner Date
WORKER'S COMPENSATION DECLARATION -
1 hereby afBm,under Penalty of perjury ane of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-imuse for Worker's COmp o-
0ation,As provided for by Section 37W Of the LidW,Code,for the performance of the
work for which this Permit is issued. ,
%(t}J
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Cade.for Ne Performance of the work for which data Permit is issued.
My Worker's ComP`yts.tion lmun artier and Policy nu
Cartier; J 7 ) Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the permit is foronc hundred dollars($101)
less.)
I certify that In the performance of the work for which this Permit is issued.I shall not
employ any person in any counteract as in become subject in the Wmkeri Compensation
Law,of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
bceoms subject to the Worker's Compensation provisions of the Lshnr Code,you must
�O forthwith comply with such provisions Or this Permit shall M deemed mvoked.
tiCONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a construction lending agency for the Performance of
Ya Y the work for which this permit la issued(Be.,309],Civ.C.)
YQLenderi Name
Z Lender,Address
;)Q 1 certify that I have mad this application and rete Char Nc above information is
I. F correct.I agree to comply with all city and county ominamss and sum laws relating te
„ building construction,and hereby authorine mexnutisa of this city to ester upon to
Wahovc-noodoned property for Inspection Pu poses.
(We)agree to save,indemnify and keep harmless the City Of Cupertino against
y liabilities,judimods,costs and expenses which may is any way accrue against said City
J 7 in consequence of the groming Of this Permit.
G' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S_ Date
SOU //GUU��tL((7�� NNS��++1��155ss`��` /D ^ ��`�
Sigmm f coApplicanUContncio Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupmt a..or handle hazardous material
As defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Calc,Section 15533(.)? All roofs shall be inspected prior to any roofing material being installed.
Yes '12".
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
it hmamnus air contaminants As Bcrined by the Bay Area Air Quality Management
all new materials for inspection.
strict?
❑Yes P&
I have mad the hazardous materials requimmems under Chapter 695 of de Cali for.
nice Health&Safety Code.Sections 15505,15533 and 25534.1 understand muifthe building
Jnr not currently have a tenant.Nat it is my responsibility m and fy the oceupem of Nc
oundom"hich sthemet poo,toAidnmoraDoor, mofOccupancy. Signature of Applicant Date
�C G�L1 fib- F-6 3
Owner ora thoriecd agent Data All roof coverings to be Class "B" or better
CITY OF CUPERTINO 0 7 1
WATER HEATER
CUPEf�TINO PERMIT APPLICATION FORM
APN# 32— l Date: /Oh) 9 �2
Building Address: ,
Owner's Name: Phon
ho 01-1f,"J6
Contractor: Phone License#:
ContaSt: o e: Cupertino Business License#:
nju lsUt`9y1L s�) � 3y5�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb W Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Sid
. Strapped 0 On Platform LJ Bonded El
New Location ❑ Replacement
Qty
A c bl Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING