03080148 CITY OF CUPEWFINO t ^".:- '�.gz 'w,,,t..$
BUILDING DIVISION PERMIT CON,TTRACTOR�INFORMATION "
f OUILOINGADDRESS: HOT WATER ZINC PERMITNG03080148
rAA GRANADA AV
Ll
OW NER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
JNE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION Job Description
M1 hereby affirm that I em licensed under provisions of Chapter 9(commencing p
with Section]rep of Division 5 of the Businu and Pr sisinm Code,and my license is
± � in muntmeand fie . _W,( 3(p( REPLACE WATER HEATER
yqg License l4 UU�4�Lk.Y
-FO Dam SSS C.,me r
ARCHITECTS DECLARATION'
I U 1 understand my plans shall be used es public rcomd .
6
r�G Licensed Pmfcuional
3 atIAm OWNER-BUILDER DECLARATION
<Y 1 hunchy,(Sero the I em.Bumps from the COmnnteod License Law for the
mfollowing mama.(Section 7031.5.Business m r ve de tau Code:Any city or roomy
which itsisaae,also Inconstruct.the alter,improve demolish.ore asiranyatmmum
3Z triton iuiensedprsuant In the the farsuch Commrmil miens Lw(Cha mcnt
`e
that hciscin,widpSectio 70M)ofDivimm�fthe oftheBusines'snittnulsw(Chaptcr9 Sq. Ft. Floor Area Valuation
` $ 'at he B exempt
Section70M)and of Division r the
theeged Businessand
Puesson.Any
yovi Cnde)or
Natio k exempt therefrom and or aper for the alleged cremation.Any violation of
Out nun]0an I,.any applicant llars( etmittuajauthe applicant ,civil penalty of APNNumber Occupancy Type .
not marc Nen Bw hundred dollen(5500). '"-' -" —-- "
❑ I,m wnernftbepmpcny,wmyemploycuwiNwageau NeirmlecomM=tlon,
will do the work,and lite svucmt is not intended or offend for sale(Sec.]044,Business 502 - FINAL iRL JnFtcWaFRGY
and Profession,Code:The Contractor,License Law dose not apply Of an owner of
property who build,or improves thereon,and who does such work himselforthrough hit 506 - GAS TES
own employes,provided that mh improvements Are not intended orolfmad for sale If. FINAL PLUMBING
however,lie building or improvement is sold within one yeti orcompletion,the owner. —
builder will have the bordcn of proving that he did not build or improw Be purpose or
sato.).
0 1,As owner of the property,am exclusively contracting with licensed convectors to D- f
construct the project(Sec.]044,Businessand Profession.Code:)The Contncmh Li•
tirec Law does not apply to an owner ofproperty who builds or improws Baton,rodwho contracts for such projects wish a contractor(j) amhlicensed pursuant to the ConuLicense Law.
❑1Am exempt under Sec. ,B&P C for this reasonowner I _WORKER'S COMPENSATION DECLARATTIOON ...
I hereby affirm under penalty of perjury one of the following devaluations:
1 haw and will maintain a CeNReat of Consent to self-insue for Worker's Compri
ation,As provided for by Section 37M of the Labor Cade,for the performance or the - - - -
work for which this permit is issued.
�C]vl have and will maintain Worker's Compensation luunnce,As requited by ScrUon
of the Isbm Code,for one performance of the work for which this permit it issued.
My
Worker',Qnm�epuOon In senna carrier and Politynulmberar038e;p rs
Cameo vj"g policy NO.: 4-N (o
CERTI KATE OF EXEMPTION FROM WORKERS''
COMPENSATION INSURANCE
(This section need not becomploted if the permit is for ane hundred dnllvs(SIM)
leu.)
I comfy that in the performance of the work for which this Permit is issued,1 shell net
employ any person in any manner to sew become subject o the Workeri Compensation
Laws of California,Date
Applicant
NOTICE TO APPLICANT.If,after making this Cenifu:aue of Exemption,you should
become subject to the Workers Compensation pmvitimn of the Labor Code.you most
z forthwith comply with such provisions at this permit shall he deemed¢yoked.
ti O CONSTRUCTION LENDING AGENCY
1 hereby oMrm that there ire couqucvhm knding agency for IM perf vmaoec of
:4the work for which this permit is issued(See.30n,Civ.CJ
.1 Q Lenders Name
z Lender's Address
p 1 certify that 1 haw read this application end tut that the Above information is
F cotmingcontr to comply with
yAtuhantl county ordinances and sou laws
nteruprelating duc 9-
in
Ushowngcnionedon,an0 bor Beeman mrepruentslives of tail city Bo tour upon theNovo-(We) greproperty forImnifyanpurposes(We)agree toe cove,indemnify and high AYin An Ik City of Cupertino against
H consequence fthero56and Ofpenaaiieh may In aey way aaNe agaln,l3altl City APPLICANT
of the Sterling of this Form it
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGliar1(�I4S�x �(. � U�
`�'(`��. Re-roofs
Signature of ApplieanUConuactor C Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupar sire,or handle haurdors material
As dented by tiro CuNnlno Municipal Code,Chapter 9,12.and the Health and Safety
Iducirmourrently
de,Section 35533(,)? All roofs shall be inspected prior to any roofing material being installed.
❑Yon ONO
Will the aPplicmt or future building occupant use equipment or dcvicet which If a roof is installed without first obtaining an inspection,I agree to remove
it hvardous air contaminants a defined by tM Bay Area Air Quality Management all new.materials for inspection.
atrict7
C]Y., ❑No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor,
Health&Safety Cade.Sav 35585,35533ant35574.1undcmm�dthalifthe building
uitmcnu w be m t prior m issuance of a Ccnihcate of Occu m
ck d� (/o� Signature of Applicant Date
Owner of authorized agent Date? All roof coverings to be Class °$° OT better
CITY OF CUPERTINO
WATER HEATER
iCUPERTINO PERMIT APPLICATION FORM
APN# , Date:
1
Building Address:
c2,t lQQ ' U"
Owner's Name: Phone*
1�,AL) (f-/09) yYG -�S5'f
Contractor: Pho -. Li nse#:
Contact: Pho : Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Vh Commercial ❑
Cost of Project:
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement to
Qty. if
AppliFee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
-2�-L�/ �o