04050060 CITY OF CUPERTINO � ?
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
ZIUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT NO 04050060
7
OWNER'S NAME: PERMR ISSUE DATE
BINA BHATTIAM A AND
ONE: SANITARY NO. CONTROL NO.
(510) 376-4816
ARCHITECTIENGINEER. BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
unit LICENSED CONTRACTOR'S DECLARATION
1 hereby motor Net 1 am limned under,p -sioiu of Chapter 9(commencing lob Description
with Section] of Division3drthe Businr Porfessiom Codd,and my license is u n LE
�
r „ imtor_ZL
m�rpmewrr 79g�j� REPLACE WATER HEATER tf"— IJ�(�.,
q z o erase .mk Con vae
CHITECTS DE IDN JUN' 7 2004
1 undefnand my plans shall b[used Or public rt.ms
0-U
3aG Licensed Promeiprud n
LV
Q 3 OWNER-BUILDER DECLARATION �11 U�IOtj ®�Nnll�
d F 1 Mreby affirm that I am exempt form the eonaaaols Licensc law for the
o O following mason.(Section 7031.5.Buru arta sinProcession Cods:Any city.,roomy
µQ r which mquima a permit to construct,alter.improv,demolish,or mpar any stratum
at–t^ prior in its issuance,3150 requires the applicant for such permit 10 File a signed statement
i—< thatheislicensedpursuanttotheprovisionsofNeComrwmr'sLicenselaw(Chapter9 Sq.Ft.Floor Area Valuation
1�0 (commencing with Sodom 7")or Division 3 of Rhe Business and Professions Cause)or
ed
that he is acmpl therefrom and Use insist fm the alleged exemption.Any violathem of
Section 7031.5 by My applicant fors permit Mbjc.the applicant to a civil perulty of 3.r�I3ej5r&er0 0 Occupancy Type
not mart than Bw hundred dollen($500). J
I,as owner of the property,or my employcn with wages u their sole compensation.
will do the work,and the suucmm is not intended or offered for sale(Sec.IDN,Bu5lnns
and Pmfcssiom Code:The Contracmh Liccrue law don not apply m an owner of Required Inspections
property who builds or improves thereon,and who does such work himself car through his
awn employes.provided Nat such improvement,see not intended oroffesed for tele IL
however.the building car improvement is mold within ane year of completion,the ower.
builder will bavu the burden of proving that he did not build car improve for purpo¢of
sale.).
0 1.as owner of the property,am exclusively contracting with licensed contractors in
cowwn Ne project(Sec.7614.Business and Pmfesaors Code:)The Compactors Li.
terse law docs not apply be an owner of propery who builds or improves Hyman.and
who contracts for such porject,with a eonuaelor(s)limned pursuant m the conuanoh
License law.
I am exempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hemby off rm untie,pcugly of perjury oro of the following declarations:
I haw and will maintain a CcrtiOcam of Comcnuo selRinsurt forworkcNcump[m
Motor,ass provided for by Section 3700 Of the labor Cade,for the performance of the
work for which this permit is noted.
❑1 haw and will maiman Workers Compcnsauon Insurance,as"timd by Section
3700 of the labor Cede.for the performance of the work for which this permit is issued.
My Workers Cn Inwranm caniv and Policy number am:
Carrier. Policy No:
CERTIFICATE OF EKEMPnfII'1 fpOM W DRKERS'
COMPENSATION INSURANCE
(Thu¢cellon need nothecomplered if Rhe permit is form hundmddollan($100)
or Ica.)
1 certify that in the perfomu s,of the work for which this permit u based.I shall nm
employ any person in any manner an as to become subject to the Worker!Compnw0on
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CcniOcne of Exemption,you should
become subject to the Worka'f Compensation provisions of um IaMr Crude,you mow
Z fordwith comply with such pmviuoM of this permit ahldl Ise doemed remked.
Z O CONSTRUCTION LENDING AGENCY
F" I herebyarsm that them iia emmusednn lending agency for the performana01'
the..,it for which this permit is untied(Sec.3097.Civ,C.)
!1)z Lenders AMName /
U 0 1 ratify that I haw read this application and mut,that Ne minces informauun is
(L U coeecL 1 agree m comply with all city and county ordinsnceS and sum laws mitring m
C) building construction,and hereby antharim mpremnutivn of this city m enter upon the
W about-mentioed property for inspection purposes.
6. (We)agree to Mw,indemnify and keep hatmleo Bra City of Cupertino against
wF,t Imbiliuct.jodgmcns.cros and espcnan which may In any way secnmagaliol said City
UZ mcomeq=mofthcgmtingafthispnmiL
APPL AM UND SP�MB ND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOU CE - TIONS.
[ n � Re-roofs
ShTf5imeofApplicanVConoacmr Dam t
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will um applicant or future building XMPam nam or MMIC Iwardoe material
as defined by the,editors.Municipal Code,Chapter 9.12,and the Health anal Sa ly
ode.Smu m 15532(3)? All roofs shall be inspected prior to any roofing material being installed.
Y.
1 No
Will the applicant or future building Occupant use equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil Mvardous air contaminants o defined by the Bay Area Air Quality Managcmem all new materials for inspection.
D'win7
C]Yes
I have read the ourard.s materials requirements under Coupler 6.95 of the Califap
nia Health&Safety Cade,Sections 25505.M533 and 25534.1 understand that it the building
Jac not cu amnanx that itbmy rcxpomi tlnym.tily Jm cecupant of the –
( 16L which muss met ormissua.c oft rti0camof C< ane Signatl�r�. fApplicant Dale /
b 5�)3��`I All roof coverings to be Class"B"or better V
Owner or suthrrissJ ag.t Dare T
Community Development
' 10300 Torre Avenue
�- Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS PERMIT # �b -
75-53 A `�
OWNER'S NAME: PHONE # si —
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following ' ormation:
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 tj
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
® O
Owner/Contractor Signature bade
CITY OF CUPERTINO
OWATER HEATER
CUPEf�TINO PERMIT APPLICATION FORM
APN # Date:
-5,519 al oS6
Building Address:
SS
Owner's Name: Phon #:
Contractor: ,
// .Phone: !d Li nse #:
Contact- P ne: Cupertino Business License#:
!D —9D p
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cos[ of Project: /,,V
• Strapped On Platform ❑ / Bonded ❑
New Location ❑ Replacement
Q . if
A li able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING