04050106 CITY OF COPERT]NO
BUILDING DIVISION PERMIT kdCl�iTRACTORIVFO., ATION�.z,,+'
BUILDING ADDRESS: HOT WATER INC P.M.ND04.050106
,OWNER'S NAME: PERMITLSSUEDATE
JOHN METZGE
NE: SANITARYNO. CONTROL NO.
(650) 298-8494
ARCHDEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ON
-to -thatED CONTRACTORS under
DEsions f h.p Job Descr SINAL E D
I barely
affirm tNt 1 nn licensed under provisions of CMpur Y(commaneing
with ScI bar ly of of Division]of the Buainea and Profession Code.end my lic em is
n. imm�mraanderc«t REPLACE WATER HEATER
j�_ Licen�Conn
nip Dau Con DELL
ARCHITECTS OECLARA NOV ' - 2004
IunEcratanJ my plans shall Wuudu Public mmNs
w
g�M LiccnxI Professional BUILDING
OwNER-BUILDER DECLARATION
Eno Ihcrchy.(Sero theI1. attemptfromtWcantramao :ALicenchor farIbe
00 following Masten.(Section 70313,Business and .decuu Code:Any city or county
K m� which reyuima a permit to enrswee aloe improve,demolisM1.m repair any structure
prior to is issuance.now rcyuires the applicant for such permit to file a signed treatment
-�i
that he is licensed pursuant the pmvisiou of the Common's Li«uc Law(ChaplerY Sq. F[. Floor Area Valuation
ults-$ (commencing with Section 7")of Division]of NC Business and Profesiou C or
Nat he is exempt themlrom and the bub for the alleged ascription.Any violation of
Section 7031.5 by cry appliant for a penult subjem the applicant in a civil penalty,of et0 0 Occupancy Type
not mote Nan five hundred doll.n(SSW).
❑1,uownaofthepmKnyormyemploycuwiNwageauduuwlccompenution,
will do the work.and the swcmre label ntended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Committees License Law dao or apply m an Owner of q P
property who builds or improve thermn,and who docs such work himtoif or through his
awn employees.provided it..such impmvemenu art ruin ma ed aroRered forsale.If.
however.be building or improvement is sold within one yes of completion,the owner
builder will have the W Man of Proving that M did not Wild a improve for purpose of
sale.).
I.as owner of the psopeny am elusively contracting with licensed commcmn to
munnuct the project(Sec.7044.Business and Profusions Code:)The Contrrewea Li-
ere few does not apply te an owner or pfopeny who Wilds or improves thereon,and,
who contracts for such projects;with aconuacmgs)licensed pursuam to the Conuamoea
License Law.
❑I un exempt under S«. .B&P C(m Nb recon
OwnefDna
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the fallowing declarabou:
1 have and will maintain stCertifiate of consent m tol6lnsuri for Worker's Compen-
sation,u provided for by Section 3700 of the labor Code,for the Performance of the
work for which this patron is issued.
1 have and will maintain Worker's Compensation Insurance.u myuimd by Section
of the IaWr Code,for lW per amsuce of the work for which this
tthhis Permit is issued.
My Warkees C�omperlsa6on ingsun«e artier and Policy number�S?0�3„
Curter. \ /��r✓N✓1 Polity No.: t/s
v CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectinn need not x moults sed Run:permit is Im m.ltundreddollm($100)
orkss.)
1 ecnify that in Ne Performance of the work for which this Permit is issued.I shall not
employ any person to any manner su u in become subject to the Workers Compensation
Laws of California,Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceniftcau of Exemption,you should
become subject m the worker's Compensation previsions of the labor Code,you must
.J O forthwith comply with such provisions or this permit Nall W d«reed revoked.
Z� CONSTRUCTION LENDING AGENCY
Ihnmhy affirm thn Here is It conwuclion lending agcney for the Performs..of
a > the work for which this Permit is hound fSee.3097,Civ.C.)
W Q Lender's Name
6. Lender's Add.
VQ I ecnify that 1 have read this application and sum that the above information is
!I. f-' ConeeL I agree in comply with all city and county ordinances and sum laws relating in
V building consweein,and mhereby
demnifhoriman,humleaesof City Of
toenter upon the
W alwve-mmummul pmpeny for inspection purposes
(~6. (We)agree ro save,indemnify and hep harmleu the City of Cupertino egaiul
to liabiltlie.judgromeLcosu and cxpenxs which may in any way acerae against said City
U Z in comequen«of the Staining of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGUL�L�N /-T
1 fCom IJ( Re-roofs ] f ( r O
Signature of ApplicaHAZA DO / v
HAZARDOUS MATERIALS DISCLOSURE am Type of Roof
Will the applicant no future Wilding occupant sore or Intik huarduanmaterial
IT='
defined by the Cupertino Municipal Code.CT4Pur 9.12 roti the Halth and Safety
le.Section 255324)7 � All roofs shall be inspected prior to any roofing material being installed.
M Ycs
Will the applicant or future Wilding occupant into eyuipmem M devices virkh If a roof is installed without first obtaining an inspection,I agree to remove
mit hayardoe air commitments u defined by the Ray Arca Air Quality Management all new materials for inspection.
istrict? II��
❑Ycs C!R
I have med the hmallous matertalsrmmormens undercut 6.95 of tbe Califoo-
u Health&Safety Code,S«uou 25515.25533 and 25534.1 undersund thnifthe Wilding
not currently have a remand.Wt it b my responsibility m notify thc«cupid mf de
yuircmcns which muu mer�qnorm ivaao= oracetiRateoro/�aPm Signature of Applicant Date
—F�10L( All roof coverings to be Class"B"or better
Owner,anuthoro,ed agent ni,—
Community Development
10300 Torre Avenue
5;Tt1Y10Fi,V
Cupertino CA 95014
� Telephone(408)777-3228 Fax(408) 777-3333
SCUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
a r, 090,5olo6
OWNER'S NAME: ON1J '71 ( f,-,L PHONE # 3 -,9 c(g
GENERAL CONTRACTOR: C.�/� ,Z pwG FAX # O - 4(
I am not using any subcontractors: C,4�a ® 9, O
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor ignature Date
10/28/03
CITY OF CUPERTINO J S�
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 3 5 _ Z -0y9
O y p Dater � 6'/
Building Address: // C 7"
Owner's Name: i U/ Phone#:
Contractor: P ne: SD , ��O 9 Yg _ License#: ���
HOT WATER, INC.
Contact: SAN CARLOS, CALIFORNIA 9407 hone: Cupertino Business License#:
Building Permit Info: o'
Bldg ❑ Elect ❑ Plumb L5 Mech ❑
Job Description: � —� II C�, _¢�
Residential Commercial 1-1 /+
Cost of Project: J�j b
• Strapped El On Platform U Bonded ❑
New Location Re lacemen(g)
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE
Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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