05110074 CITY OFCUPERTINO
BUILDING DIVISION PERMITCU,ITRt? TR ''UitMTIQI.
BUILDING ADDRESS: AFFORDABLE WATER HEATERS PE "THO.05110074
867 HYDE AV
OWNER'S NAME: PERMIT OUR DAIS
AjhJIM WALKER 24707 SAN FERNANDQ ED 11/19/200S
14 NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHRELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O 0
ipp LICENSEDandCONTRACTORSIt= Under
derPDECons at c0N ]Ob Description
uJ 1 hereby of dm 1 3 Ikaared under and
Prol ua or Chapter 9(mmmaMng
withSectionface ndefect. n3ofthe BusinLC.# sed Pat3(4Code,sed myIkensseu
?g� amnra�md effect. �y REPLACE WATER HEATER
L� Lkcnaellsu�.(1_.LC.#A273(4'273 p
Da¢ Canlnc r
0 ARCHITECTS OEMRATION
Q 1 understand my plane shall be awl u public records
' OFC
s vd Licenced Professional
� icy OWNER-BUILDER DECLARATION n
1 hereby arlinn that I am amp,from the Coruscate,License law for the
O o fallowing reamn.(Section 7031.5.Business and Pnekstlom Code:Any city or countyoOS 1 000
$tai which requima a permit to convru0.Rim,improve,demolish,or=pair my Rrunum
zC pHoraita ouanm,Wurequima the applicant forwchro t0icasUrsed0smmem
�< thmleIs licensed purmanttoUna iaiwuaftheCanumloe,Less Law(Chalnv9 Sq.Ft. Floor Area At/ luation
$ (commencing weds Section 7000)MDivkian3 of the Business and PrOlasims Cade)or U ��'
`<— that he Is«=pr thucham and the bsm fa the alleged emmpdm.Any W0146 n of
Section 7031.5 by any applicant rat a permit subjects the applicant m a Civil Penalty M y ()GCL{p "Typo
not mare ton Bw hundred dollars(=I
❑L u owner or Ne pmp=y.or my employ=with cages u thebmk cmmpancedon,
wiBdotheworkmdtheI u isant NmndedoraRertdforuk(SW.70M,Baacus Required Inspections
mrx
and Professions Cade:The Cotae,Licen Law does WE apply a an owner of q P
Property who builds or im provea meteor.sad wo does such work hM¢If m through his
own anploycn,provided that such Improwmanu=not inteded oraRared forsale a.
however.the builde,gar lmpmwmanl b sold within cns year of ComPletiau.the Owen
olmar Mtl ow tee burden of provin{mat be did let bda or Unlearn for purism of
sale.).
❑1.u owner M the property.am aclusively eanuanin{with licensed can ramml In
cautmct the project(See 7044.Business sand Professioes Code:)The Convenors LI-
Gema taw does not apply an an owner of pmpeny whe heads or imp Ina therean,and.
woeo=mu far such pmleeta wile acmuectm(s)Ilcensed pursuant m meconlanaes
License Law.
❑I=eeemptunda See .Bd PCfardds.
Owner Dan
WORKER'S COMPENSATION DECLARATION
I hereby&Man under penalty a(petjury,m s alga following declared=
❑Ihe.and will maintains Caubeaauem m
ofCoself-Iosunefee WaleattComPm-
ander.
u provided for by Secdon 3700 M ded Labor Code.for W performance of the
wals fee which this permit is issued. -
❑1 have had will maintain Workers Compensation Inmrwem,u mquired by Section .
3700 of the labor Code,for the perfarmence of the work forwhkh this Permit is roved.
My WoAaes Compensation insurance esrtia and Policy number are:
G ia_<4 de roes tT Policy Na.:16S/c335=2`af
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
()Tis anion need notbewmpkad If the pemea Is forove hundred art=($100)
mlue.)
I«nify that in the performance M the work for which this Permit is blued.I shall for
employ any person In my manner=as a become subject in Ile Weaken'Compeceelon
Laws of California Dat ,
Applicant
NOTICE TO APPLICANT:If,afar ar t Ws CadBuat of Esempion.YOU sous
became subject a the Workees Compcosadan provisions,of the Lather Code.You muR
.,O forthwith comply with each provisions or this permit moll be deemed terminal.
7 CONSTRUCTION LENDING AGENCY
(. 1 hereby M.thv acro ta a camulcdm leading agency for dt Perfoame ese M _
C>
the wart ler which than permit k banned(San.3097.Ch.C.)
4 Q Landers Nsme '
7 Z Lenders Addrees
U o i CgNfy dot 1.
haw reed Ibis app0esdm sed d$I the de aow iMamadat i.
U.
Porta 1•{res m comply with ill city sol county ardinarees tid fat Ian relatint m
Q building construction.and
a,Inde mthand Imcpesenads,the this city atenter
atim'Aupon the
s,7 above-mentioned property,for Inspection purpose,
cn (Wo)agate m cent,indemnify and hick harmless the City of Cupertino d City
n„rZ inconsequenamentaecoming ospenwmiicln may aanynYamwatdmrsaidCity
C)Z A PLICA nee of the UNDERSTANDS
ofthisWIL Date Ur
^
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURc�n ONS. l
Re-roofs
lcanouacur Data of ApplCn4
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tit applicant or forme building oampmramre orlandle Monsanto matrix
ce denned by the Cupertino Municipal Cade.Chapter 9.11 and the Halth and Wcty
ado,section 35533(m)7 r All roofs shall be inspected prior to any roofing material being installed.
❑Yat 13<
Will the applicant or foram building aaupant am Wulp ram ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hrzamnm air conuminana an and by f Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I haw mad the hvardam materials requima cru under Chapter 6.95 or the Califon
nie Health At Safety Code.Sectioua 15505.25533 and 35534.1 understand than ifge building
gas net cwt IY a temnl dal It k m responobility m nWfY eccupanl of the
acyl t aBbe ora amteM,ceninaa01 Signature of Applicant Dale
1177162c" All roof coverings to be Class"B"or better
OW?k'ser summirt l agent - Dat
r - Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS• PERMIT #
a. {9 1r� 0S—//j0-? L1
OWNER'S NAME: L e'e Rewe PHONE # :25-5-7l 3/
GENERAL CONTRACTOR 11FFarnga/w wAtv{..th� FAX # (p6! 2sy —ST!c.
I am not using any subcontractors: 7 /1M ivy I I I 1S /,.
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
TIl
Owner/Contractor Signature Date
CITY OF CUPERTINO
' WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 3 7i Y � Date: I S I d
Builg �drress:�l
(� /iY 7)
Owner's Name: Phone#:
Strom tvAkk.�
Contractor: Phone: License#:
6FForI)AA ( T-7
Contact: Phone: Cupertino Business License#:
CJ
scb rn ���✓ G,155. 6/- 55--7/ 3 / (a 1-5
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
�prSk'^1) WAIT' hu'1`�
Residential [vf Commercial ❑
Cost of Project: f p0
Strapped U On Platform L1 Bonded
• New Location ❑ Replacement
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