05030146 CITYOFCUPERTINOkt;
BUILDING DIVISION PERMIT CONTRACTOR+INFORMATH,
BUILDING ADDRESS: HOT WATER INC PERMITN%5030146
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�+Op LICENSED CONTRACTOR'S DECLARATION
tu 1 hominy aRrm that 1 am liccnxd under proviAons of Chapter 9(commencing Job Description
-< with Section 7IX10)of Division 3 cram Business had Prefectures Coda,and my license is
_ mu nRandarr /o WATER HEATER REPLACEMENT
LIZ Liccnu CI Lm N
w_ DoleGrnlra[b
F� ash
A CHTIE
LTS DECLARATION
IIIe 1 understand my plans all W tuas used public records !!!
O/LL Littered Pmfcssirnal
i p� OWNER-BUILDER DECLARATION \
0 0 I mem v(Bnn on I em exempt faro Nc Contractor's :Any c Law for the
O O fallowing mer..(Section]cost Business and improve.
moons Code:Any city or county
$ which requires a permit re las construct.alter,improve,h Permit
fie a rig any aucmm
Fsipoor mits censed pormerssuance also rtto the poo,imappeoffur summmt iuuimits, .(chod mmcnt
Nat me liccnxdpuctiontoNcprovisionofNo eBusinssandPnxlaw(Chapmr9 Sq. F[. Floor Area Valuation
a�0 (coma,is ex opt Section and of Division]or e,al Business and Pro(cey vi Cede)or
that he u exempt therefrom and Ne baso for dx alleged exemption.My violation of
Section 7031.3 by any applicant for a permit architect the applicant to a civil penalty of 3 69TV909ef0 0 Occupancy Type
not more Nan five hundred dollars(s5(10).
El I,as no, r,ha property,or my cmployc.with wag.ss mei,sato temporation,
will do the work and Ne,tram e is not mismicd oroRned forsalc(Sec.7044,Business
and Professor Code:no Contractor's Licelue law docs nos apply at in owner of Required Inspections
property who builds or imposes themon.and who doessuch work himself or thmugh his
own employe.,provided that such imprnvemmis an,not intended oraRered tarsale.If.
however.the building or improvement is said within one year of eempledon.the owner
builder will have the burden of proving that he did not build or improve for purpose of
ae).
❑1,as owner of the promtry,am exclusively contracting with licensed contractors to
convect the project(Sec.7614.Business and Professions Code:)The Contractor's Li.
entre Law does not apply to in owner of popmny who Wilds or improve common,and
who concocts for such projects wit a comracmr(s)liccnxd pursuant to the Contractor's
License law.
❑1 am eaempt under Seo. .B&P C for Nis mann
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby offers under penally of perjury one of the following declarations
1 hove and will maintain aCmifiO4 firCarol to self-insure far Worksrf Compere
auan,as provided for by Sec..3]00 of Ne Labor Code,for Ne p rfa mance of Ne
workfarwhich Nia permit is issued.
[DSI have and will mainam Worker's Compensation[houn ec,as required by Section
37W of the Labor Code,for the perform...of Ne work for which this penis is issued.
My Workers Compensation Insurance carrier and Policy number am: p T�
Carver: _< .�iL �i M/ll Polity No.: (S'y/)�tJ(er
CERTIFICA MON FROM WORK ERS
COMPENSATION INSURANCE
(This.0m modem hem.pleted if the permit is force.hundred dollars(SIM)
or less)
1 emir,,Nm in the performance of the work for which this permit is issued,l shall not
employ any person in any mmol ser as o Wcume subject o the Workers'Compensation
Lawsof Calif naP.�tc
Applicant t sat^
become
subject u,
the Work IL alar making this Cisions of of Excmplion,you should
become su omp y cot Worker's rovismp or this provisions or do Lahr CMe,you mull
.,z foMwith comply with such provisions or this permit shill W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
EI hereby vMo.
that then is a construction lending agency for the performance of
7 the work for which this permit is issued(Sec.3097,Co.C.)
U] Q Lender's Name
G.
D Lcmicri Address
U 0 1 reify,that I have mad this application and sum Nat the eWve ws relating u
U.U correct 1 agree ct comply with all city and county cornmeal;and tum laws relating to /
QU movie-nounsing melon,and pery(m Inspection
ns authomempresenativrs of this city to enter upon the S
r a shove-(We)rn ace 1.m v.rat im indemnify
an keep hs.
(We)agme to ave,and exp ry end keep harmless the y se tar against
against
HZ income,,mar mcn¢costs and m of one greasing of this.mit. may in anyway amnc against aid City
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of Applicar Data
HAZARDODO US MATFAIALS DISCLOSURE Type of Roof
Will the pplicam or future building occupant uorc or handle ha mous material
m defined by Ne Cupertino Municipal Code,Chapmr 9.12.and Ne Health and Safety
ode. Yes 23332(a)? All roofs shall be inspected prior to any roofing material being installed.
0Yes gyla
Will the applicant or future building occupmt rex mcipmml or devices which If a roof is installed without first obtaining an inspection,I agree to remove
not ha ardoue air contaminants u defined by she Bay Area Air Quality Management all new materials for inspection.
Id.
istrict?
❑Yes Nu n
Ihavcmal Neh,Sccumamrialerequimmcn534.iuChapmrb.93ofthc Califon ^j/ C`
an,curentlyCode,Scants23305,.myro W23334.1undersande arc Wilding (/ J /l t currently have a memo Uat it u my respomibilily o nnul'y Nc esu t err Ncbc:.Z10,miewe"of aC.Embeaf Signature of Applicant Date
^ '���� — �� � All roof coverings to be Class"B"or better
wner or mOodyml agent Date
-" Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�.UPERTINO
Building De artment
JOB ADDRESS: a I 3 PERMIT # 0,5--o
, --O 3 ()f ,l6
tP ✓' b
OWNER'S NAME: Do o r eS h o PHONE # 9pg- - 6
GENERAL CONTRACTOR: ti r FAX # ( S )-
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 , a 38
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
41 3////6-5
Owner/Contractor Signature Date
s� CITY OF CUPERTINO o�-u 3
WATER HEATER
Y OF
CUPEkTINO PERMIT APPLICATION FORM
APN#. Date:
Building Address:
Owner's Name: Phone#:
Dol ccC o oq- -,�?S7- I �
Contractor: Phone: License#:
t a.7 (- -Inc, 65-0- 631- 63 G
Contact: Phone: Cupertino Business License#:
r�kCj'S uslAVj1 - Pq 311
Building Permit Info: /
BldgElEl —
Elect Plumb l,� Mech ❑ .
Job Description: <5=2�,5 iM (c Yt_o_S*N a ci FS
to - v fe V-1 or
Residenti Commercial ❑
Cost of Project: �;D 0
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replace ent
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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