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CITY OF CUPERTINO�,`^�
BUILDING DIVISION PERMIT
WON+TRACTOR INFORMATIO
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BUILDING ADDRESS:
WATER HEATERS ONLY
PERMIT NOD4010011
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
I hereby affirm Net 1 am licensed un pre�susCs •! LNr P� 9 (commencing
with Section7000) foivki Sof me Basin and res dmyliCcoat,
¢l.
in full force and e �n
3 •
REPLACE WATER HEATER
Li Class e
Da¢
ARCHI CTS DECLARATION
'
I understand my plans shall he used as public records
FINA LED
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
2 2 2004
following moon. (Seaton 7031.5. Business and Profession Cale: Any City car County
JAN
which requires a permit m construct, alter, improve, demolish, or repair any structure
! Prior In its issuance, 2150 mquins one applicant for such Perrot to file a signed stammcmt
Contractor's License law(Chapmr 9
Sq. Ft. Floor Area
pe't�D'�7nIRHLIOD
i that he is licensed pursuant to the pmvisi0m or the
( (commencing with Scelion 70W)of Division 3 o the B usmcas and Professions Cmde)or
BU L �1�V
. that he is exempt therefrom and the basis for the alleged eacreption. Any violation of
3 MN4,bi0gr0 0
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penally Of
not mom than firs hundred dollars (5300)
Q 1. as owner of the property, or my emplayew with wages as their sole compensation,
Required Inspections
will do the work and theswcture is not intended OroRcood at sale (See. 7014. Business
and Pmressmne Code: TTe Connector's Liccme Law dam not apply to an Owner or
prolan who builds or improves thereon, and who doessuch work himsolf orthrough his
own employers, pmvidcd that such improvements are not inteMed oroRera forvk. IL
however, me building or improvement i5 sold within one year of mmplelion, the owner.
builder will hale the burden of proving that he did not Wild or improve for DOTosc of
n1e.).
Q I, uer of Inc property, am exclusively contracting with licensed contractors to
Construct the project Sec* 7044. Business and Professions Code:) The Contractors Ll.
come Law does not apply to an owner of property who Wilds or improves thereon, and
who contracts for such projects with a eonuactoms) liamed pursuant to Inc Contractors
License law.
Q 1 o exempt under Sec . B k P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby TO. under penally of perjury one of the following deelantiau:
1 haw and will maintain a Certificate of Consent to ul6insura for Wonders Compen-
,
pion, as provided for by Section 37M Of the Labor Code, for Ne performance Of the
for which this permit taunted.
1 have and will maintain Worker Compensation Insurance, as required by Section
700 of me IaWr Code, fur the performance of the work for which this Permit is issued.
My Worker's Core%�ti�o�n lnsu{g/ptt canicnnd Policy number am:
Caro / �""'� Policy No.: 166-5yZ3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he COMPRICd if the Permit is for one hundmd dollars (5100)
'
or less)
1 comfy that in the performance of the work for which this permit is issued. I shall not
-
employanypertaninmymannceinastobecomesubjecltotheWorkeriComperoketi e
-
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL aper making Ibis CCrtificato of Eacmpsion. you Arnold
became subject to the Workers Cam Kniation provisions of the Labor Code, you must
f."with Comply with such ret isio. or Nis Permit snail rte deemed revoked.
CONSTRUCTION LENDING AGENCY
1hereby that hereisa Com Wetimn lending aecnry for the Performance of
ich hi
the work far which mine permit is issued (ser. 3091, civ. Cd
jLender's Name
lander: Aaarees
I certify that I haw read this application and sum that me move information is
` Correct. I agree to comply wise all city and county on inamma and Sam laws mlating to
molding Construction, and hereby authorise rcprmcntatives of this city to enter upon the
almn-mentimod pmperty rte impeCvom Purposes
(We) agree to save. indemnify and keep harmless the City of Cupertino against
Iiabilidu.ludgmcnts. costs and capcmesw icIt may in any way CO. against said City
in consequcncc of grantingu hers t.
' APPLICANT ERSf D ILL C LY W LL NON OINT
Issued by: Date
souRc
Re -roofs
/ � ` � O 7
Type of Roof / Jl
`/
Sigmmrc Of ApplicanJConnacmr tea¢ rr
HAZARDOUS MATE RIALS DISCLOSURE
Will the m (Muni building stem or handle material
Hcallous
cCupapplicant
e. Chapter
As defined by Ne Cupertino Municipal COM. ChaPmr 9.11, aro the Health and Safety
Cao. Section 3.5531(a)y
All roofs shall be inspected prior to any roofing material being installed.
❑Ym ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
win the appheanI or marc building occupant use equipment car devices whim
it havdNlsm air conuminants As dcfincd by the Bay Area Air Quality Management
all new materials for inspection.
PIRA 1
QYcx u
I have mad the havrdous materials requirements under Chapter 6,95 of me Califno
nu Hcalth k SafetyCodc. Satan 35505.15533 end 35534.1 understand tus if the Wilding
docs not Cullen how a moans, th y ma sibilily to madly the aeuPant of the
myaimmcn en 0 tss,,.. ACeN4otc.fOccy.�
Signature of Applicant Date
9 -a~ r //a
All roof coverings to be Class "B" or better
Owner oraamorixrdAt. atc
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
0 �L O ( O U //
n
APN # 3f-6! v G,�
Date: 16 /03
Building Address: (1
2/8'3 Lc t�yL•,���
Owner's Name:oM-'o a�L. Le
Phone #:S D 6 FS 6 9
Contractor O
License #: ils � z 3
Contact:
Phone #: �''O o P3 S -S 9 4/ fo
Applicant/Coff4aetor:
,�• - IU•/j-
�Sioj51/ 12 z
Building Permit Info:
Bldg Elect Iumb Mech
Job Description:
esidential• Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:
Type of Construction:
Occupancy Group:
Qty. if
AvOicable
IM"I
Fee Descrintion
Fee C;rnun
/ BENERGY
Energy
BUILDING
BPWHEATER
Water Heater / Vent
BUILDING
/ PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILIDNG
BMITIGAT
Housing Mitigation Fee
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
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