03090084 COPY OF CUPERTINO
BUILDING DIVISION PERMIT },,CONTRACTOR INFORMAT QNB
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT"Qi3090084
U965 HYANN12PORT DR.
OWNER'S NAME: PERMIT ISSUE DATE
111
170 BRANNON DR
NE: 3
(510) 376-4816 SANITARY NO. CONTROL NO.
ARCHOE-C(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
scZ Q Q
woo LICENSED CONTRACTOR'S DECLARATION
£to 1 hereby affirm that 1 am Emitted under provisions or chapter 9(commencing Job Description
i<i iwith Section](111(17 of Division3ufth Bu it m
dPfcssions Code,and my license is
< in full and cf t.
;q= L;c.nS iaa, see,.�_13/- 0 7 6 0 0 9' REPLACE WATER HEATER /J/
-Fo Dam cunmstt/ 7 H E ,n
v RCHITECTS DECLARATION Q
fly-a 1 understand my plans shall W used as public records 3
7aU
Licensed Professional
g OWNER-BUILDER DECLARATION
a I I hereby affirm that 1 am exempt from the Contractor's License Law for the
O O following reason.(Section 7031.5,Business and Pmfcitums Codc:Any city nr county
which requires a permit to construct,alter,improve,demolish,he repair any structure
azi prior to its issuance.also"mics,the applicant for such permit to file a signed Statement
that he is licensed pursuant to the Provisions pr the Comncwr's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
rt- (commencing wi in Section 794)of Division 3 of the B usiness and Professions Code)in
`<$
that he is exempt Therefrom and the basis for the alleged exemption,Any violation of 35607017 . 00
Section 7071.5 by any applicant(or a permit subjects the applicant to a civil penalty of APN Number W,more 0.Fivehundred dolmgDRKB. - .__ OecupaneyType_.
prorty, . .__._ .
❑I,as owner of the peor my employees with wages as their welt compensation,
will do the were and me swau ,is not intended or offered for sale(See 7 ,1,Business iub —
.it Profetsidne Codc:The Contractors Lt..Taw docs not apply in an owxr of
property who builds or improves thereon,and who does such work himselfor through his 202 - UNDERF U UMkT G
own employees,provided that such improvements are not intended or offered for aide,If. 301 — ROUGH PLUMBING
however.the building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving that be did not baud or improve for purpose of
302 - TUB & OR SHOWER
sate.).
❑I.as owner of the property.am exclusively contacting with licensed contramrs to 502 - FINAL PLUMBING ENERGY
consumer the project(Sec.70,14,Business and Professions Code:)The Contractor's Lb 506 — GAS TEST'
Centre law does not apply to an owner of property who builds or improves thereon,and. 507 — FINAL PLUMBING
who contracts for such projects with a contactor(s)licensed pursuant to de Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this recon
Own" Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will mainum a Ceni lease of Consents.cif-insure(or Worker.Compere
IiTy
on.az provided for by Section 3700 of the labor Code,for the perPormarme of me
rk for which this permil is issued.
1 have and will maintain Worker's Compensation Insurance,az required by Section
0 of me labor Code,for the performance of the work for which this permit is issued.
Worke5r&C pe¢tion In nntt Cartier and Policy m Pr`7T KATE OF E% M ON AN WORKERS'
COMPENSATIO RANGE
,if less.)CITU section need not W complex d if the permit is for one hundred dollars($Iro)
1 unify Nat in the performance of the work for which this permit is issued.l shall not
employ any person in any manner an az on become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cet iEcato of Exemption,you should
become subject to the Worker a Compensation provisions of the Tatem Cole,you must
�Q forthwith entirely with such provisions or this permit shall le,deemed revoked,
y fjy CONSTRUCTION LENDING AGENCY
1 hereby affirm mat more is a construction lending agency for the perfurmance of
X the work(Of which this permit is tssoed(See 7097,Co.C.)
11 Lender's Name
3 lander',,Address
:.7 Q 1 unify that 1 have read this application and sure that the above information is
cortect.l agmr to comply with all city and county ordinances and some laws relating 1p
�U building eommoction.and beery authom depresenatives of this city to enter upon the
LU ahovcmcmioned Propertycosts
for inspection purposes.
G (We)agree m save,indemnify and keep harmless the City of Cupertino against
N incoidepurom of
cpstsand expenses which may inany why accrue¢gains and City
Uz in consequence of the gaming of This permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S RCE REGULATIONS,
>� -,04 � _//` 3 Re-roofs
Signature of ApplaanUConlncror Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building excupant store it,handle havarduus Imperial
az
c.dcfned by the Cuyenino Municipal Code.Chapter 9.12,and the Health and Safety
CodSection]3572(¢)?
0y. ®,Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
It 0000dnus air conmminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
is icn?
C]Yes JKNe
1 have read the hicaNnus materials requirements under Chapter 6.95 of the Califor-
ninHcalth&Safety Cole,Seemn.25505.25533and2553,1.1 un do and the i(tM Wilding
drew not curmndy hoc a mnanT mat it is my rcapostihiliry w nt fy the cupent of dtc
eyuirem ts wy'Tn must be et pour lo'ssuance of a CeNfcam f aim c"
�/✓A.;,/ ;/� /�_ Signature of Applicant Date
Owner or auth need agent D,m All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Add
l 6S �s
Owner's Name: s � e #: p
Contractor: Phone: !� LiP nse #:
o C �9 D
Contact P ne: Cupertino Business License#:
p
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: rib ----
Strapped On latform Bonded ❑
New Location Re lacement
Qty. if
A ble Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
�g . •b I