03120071 CITY OF CUPERTINO "'�
B UILDING DIVISION PERMIT �iCO3NTRAC-TORIINI+,ORMATION k - - -
BUILDING ADDRESS: HOT WATER INC PERMITND03120071
20
OWNER'S NAME: PERMIT ISSUE DATE
KATHERINE KA
NE: SANITARYqgWia NO.
65
A0.CHTIECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
iloo LICENSED CONTRACTOR'S DECLARATION Job Description
Ig F I Mrtby affirm Ihsl I am licensed under provisions of Chapter 9(commencing
P
^m'uj with Section 7")of Division 3ofdm Buttrey and profeufuv Code.and my lfcerscu
nfull(anaand elf
e ?(o3(ofL REPLACE WATER HEATER
ZLicense CI s o
n l- Date Comrano s-.A /a-'^
qq ARCHITECTS DECLARATION
2 ac J myRlans a�M used as pudic rccorda
w C C l
3 0 Lia +fewonal 7
UIL
OW NER-BDER DECLARATION
i I 1 herthy affirm that I am exempt form the CamnaUors License Law futile
00 following mason(Safion 9(131.5,Business and professions Code:Any city or county
$ which requires a Permit to CO.".eller,immove,demolish.or rePon any nnucmrt go
FZi
prior a,its also require;On,applicant for Inch permit to rile a signed statement Valuatio
< sha W is licensesu
d puranl m the provisions of Ne Cmuraeur'Wacnm lsw(Chapter 9 Sq. Ft.Floor Area
(commencing with Section"IOW)of Division 3 of the Busimulmd Professions Cook).1
..
One be Is exempt durtfrom and the basis fa she alleged eaonpdon.Any violation of
Seedod 9031.5 by myapplicantfor a permit ubjects the applicant m a civil Penalty of 3G1nMZAq;/00 Occupancy Type
nm mom Nan five hundred dollars(SSW).
I,ssownU of the porpr+tY•UmY cmployas with wagavdeu sole ampcnntion,
will do Ncwonk and Nestmcmm is not intended Unlisted formic(See.7W.Business Required Inspections
and Prono,fma Code The ConuacmYs Lt..Law dors nos apply m an owner of q P
propeny who builds or improve,the non,and who doesmeh work himselforshmugh his
nwnemployev,providedshatsuchimprowmenuartnoti"te anofferedforfile.IL
however.the Wilding or improvement is sold within one year of completion,the owner. � s
builder will haw the Wrden of proving that he did not Wild or improve far purpose of �'��p
talc.). FINAL
M3
I,as swear of she prapany,Me uelusiwly contrseling wish licensed comractors In
construct the project(Sec.7014.Business and Profusions Cade)The Contractor's U. ,1 Al O 2oa4
cove law dos not apply in an owner of pmpny who Wilds or improves Ihemon,ad. J u Ps
who contracts for such porjeeu with a eo ills on(s)licenud pursuant m Ila Contractor's
Lana law. BUILDING
❑1 am nempl antler Sec. .B&P Clor this mason Oro V'LD
Owe Date
WORKER'S COMPENSATION DECLARATION
1 hereby effort under PcMUy of perjury One of she following declarations:
I ban and will maintain a Cenifirnu of Consent to self-insure for Waukee.Compen.
n
ation.as provided for by Section 39W of the Labor Cade,for de perfmurama of the
ork for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the Label Coda for Ne perkome,ke of she work for which Nis permit is issued.
yWorkersCo�vatian Insura�carrier and Policy number artamcr. S ( I �l^/7 Policy No.:OaP—
CERTIFlGTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed If the Permit Is forone hundred dollars($1 00)
or less.)
I certify that in the performance of the work for which Nis Perot'is issued,l"I nut
employ any perm.in any manorsen as se become subject to the Workcri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:if,after making this Cendicau of Exemption,you should
become subject in the worker'a Compensation previsions of she labor Code.you mmt
,J Z forthwith comply with such provisions or this permit shall W deemed ranked.
Z O CONSTRUCTION LENDING AGENCY
EIthereby affirm onOpera is.construction lendingapcmy for the penfurmana of
> de work fur which Nu pemsit is issued(Sec.3097,Co.C.)
IQ 0 1-snd.e.Name
P. Lenders Address
U O I certify Nal 1 bow mad Nis applicuion asd state Nat the aWve infomlNun u
1, correct.1 agra on comply with all city and county ordinances and sou laws relating to
0U building
We)., ion,and
w,indemnmhoriaepmaemetivv of this OfCalay to nmrupnnds
above-mentioned property for insPcctian Purposes
(eds)agree m save.indemnify and keep may
in m the City mCupcnit l against I
y inconseque dgmcnm coming expenses which may in any way aamc against City 1
IJz Aconsequence of UNDERSTANof DS
Peretti. Dae
r-. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE
IlesATIDN .
.i��!� t_z W(D Re-roofs
Signature of Applicam,Conwcon Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant atom of handle havardous material
as defined by Ne Cupenom Municipal Code.Chapter 9.11.and she Hedth and Safety
Code.Section M31(a)9 All roofs shall be inspected prior to any roofing material being installed.
Dy. >"Nu
Will she applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haeum us air contaminants a defined by she Bay Area Air Quality Management all new materials for inspection.
Diavia9
Oyes IrlusNu
I have mad the Rvallous materials requirements under Chapter 6,95 of the Califor.
ria Health 8 SakyCode.Sectioru 15505.15533 and 15534.1 un lcnuM del ifshe Wilding
dam not currently haw a¢rant shat it u my rvponsmili y or notify the Occupant or the
re,immcy..wpielynyR kpriormiamananf.Cwrcae ro al . 3 Signature of Applicant Date
�( Y a ale fI T Dao All roof coverings to be Class"B" or better
Owner or milu need agent
CITY OF CUPERTINO
D WATER HEATER U 3l Z c- ' 71
CITY OF
CUPEkTINO PERMIT APPLICATION FORM
APN # � b/ � Date:
Building Address: 'Lo
C)0 at-tit?d Ca. 55D/
Owner's Name: Phone
Were 7`7� �dB 57. 0yZ9
Contractor: hone: icens #:
Contact: Phone: Cupertino Business License#:
o -34
Building Permit Info:
Bldg ❑ Elect ❑ Plumb (Jd' Mech ❑
Job Description: 0,a� o6zt�
Residential 9� Commercial ❑
Cost of Project:
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement Ei�/
Qty. if
A li b e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2� �-3 2