03090017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CO NTRAUTOR2INFORMATION «:
BUILDING ADDRESS: HOT WATER INC PERMIT'903090017
'ERS NAME: 2531 GRACELAND AVE PERMIT ISSUE DAIS
PHONE: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
PLUMB MECH
i00 LICENSED CONTRACTOR'S DECLARATION �'Jpb D'eSCfII IIOII
e U F I hereby affirm that I am licemed under provisions or Chapter 9(commencing i, P
with Section 7080).(Division Sof Ne Busi sssand Professions Code.and mylicenm0
jNH in full forte and circ /�Y 2'_
Z Licenec �� `r"`tL.N �`-�
JF Date Camracbr U iL.I,
ARCHITECT'S DECLARATION If
i Iunderstand myplans mail beusedaspublic records WATERHEATER
esu
IOG Lkcnsed Pmkssiaml
j4y5 OWNER-BUILDER DECLARATION
U I hereby infirm that I am exempt from the Conuanara License Law for the
COO O following ninon.(Section 703 LS,Business and Pmfessiou Code:Any city or county
<$r which reyairts a permit m construct,filter,borrow.dcmolixh.or repair any itrucune
prior to its issuance,also requires the applicant for such permiuo Ne a signed statement
< that he is licensed pursuant to the previsions of be Combutar's Lieensc Law(Climber 9 Sq.Ft. Floor Area Valuation
2F0 (commencing with Section 7")of Division 3 of the Business and Professions Cook)or
our her is exempt thcmfrom and use buds for dre alleged exemption.Any violat(an of $500
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penally of APN Number Occupancy Type
not more than five hundred doll...($500). - ------- - -
ED I,as owner or the pmpeny,or my employees with wages u their sole compensation, 36610135 . 00
will do the work,and Nestructum is nut intended or afr,.d Ross].Ism 7W.Business Required Inspections
and Profen iota Code:The Contractor's License raw docs not apply to an owner of q p
property who builds or improves thereon,end who d.,uch work himself.,through his
Own employees,provided that uch improvements tie not hounded or offered for sale.If, 106 - -SEWER & WATER
however,the building or improvement is mid within one yur of completion,the owner.
builde,will have be,When of proving that Is,did not Wild or improve for purpose of 202 - UNDERFLOOR PLUMBING
ml`')' 301 - ROUGH PLUMBING
❑1,a owner of darproject
Sec.70X vin exclusivelynesand
commons with littmed ronVacs.n m
comwmdoes nompplyIn an Owneinestmdry,who
Code:) po Commmri Li 302 - TUB & OR SHOWER
must
ocontrd.esnsuch plyban Owner rorpmpenywWWRmosimprowa themon.md. 502 - FINAL PLUMBING ENERGY
who cantos.(of such pmjecu with v contmso,(,)licemed pursuant b the ContnaoM1
License raw. 506 - GAS TEST
1 aro exempt under Sec. B&P C for this moon
507 - FINAL PLUMBING
er Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following declensions:
❑1 have and will maintain a Certificate of Consent to self-insum for Warder's Compere
Indian,as provided for by Section 3700 of the Labor Code,for the peHnrmance,of the
work for which this permit is issued.
have and will maintain Workers Compensation Inm..nce,as required by Sudan
W I of see labor Cade,for the performance of Ne work for which Ni,permit is issued.
My Workers Compensation Insurance tinier and Policy monk pe:
Carrier: WWT� ,lk T:kv24N policy No,monk
10(.X
CERTIFICATE OF EKE !MON MOM WORKERS
COMPENSATION INSURANCE
nody.,I...it wt a complued if she permit I.(..be hundred dollm(SIM)
Of lux)
1 unity Net in the performance of the work for which his permit is issued.I shell out
employ any person in any manner an u in Wcome subject n the Workeri Compema0on
Laws of California,Data
Applicant
NOTICE TO APPLICANT.IL after making this Centaurs of Exemption,you should
become subject to the Worker's Compensation previsions of the lahor Code,you muss
7z forthwith comply with such provisions of this permit shall be dmmed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there i,a comwctur,lending agency for the performance of -
Y> the work for which this perm it is issued(Sec.3097,Ci,C.)
Z]Q Lender.Name
jLcnderi Address
Q I unity Nat 1 have bad this application and some that Ne above information is
1. F correct,1&&rte 10 comply with all city and county ordinances and sure laws relating to
0Ubuilding construction.and hereby authorise representatives of this city to enter upon fee
J+Walwve-mentiuned property rp
ror inspection puose
M s
(We)agree to saw,indemnify and keep harmless the City Of Cupertino agsiml
y liabilities,judgmcnu.cam m&&
and expense,which may in my way accainn mid City
;jz in commutator,of be Bramirg of this permit, � �
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOWT Issued by: Date
� l J
SOURCE REG fI' OA O y O
Re-roofs
Signatureof AppliuData
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will Nc applicam Of future building occupant store or handle havardous material
u defined the Cinna?nn Municipal Code,Clutpur 9.12.and the HceIN and Safety
c.Section
0Yu
134. All roofs shall be inspected prior to any roofing material being installed.
Will the aPPlicansof future building ottap or use equipment or devices which .If a roof is installed without first obtaining an inspection, I agree to remove
curls homednu air cmuminants as d.rncd by the Bay Area Air Quality Management
Dlitelcl? all new materials for inspection.
❑Yes Re
I have read the ha.ardtms materials requircotenu under Chapter 6,95 of the Califs.
nia Hut"SafesyCode,Students 25505,25533 W2553s.I understand Nm irtltc Wilding
Jma nos curmmly ho e I unmt,Nu it u my bsp.mihility b wtilj IW muuput of the
reyuircmcnuyw mtyetney�.;.rbP.r.cc,dBc,te nfb'03�,� Signature of Applicant Date
Dome,ora.'dWrrimdagent /1} D, All roof coverings to be Class"B"or better
vo3o qoo :�_
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
v3 v�
Building Address:
Owner's Name:
Contractor: Ph �f'cQ Yf License#:
l cn/�I �T
� �L� (43GIZ
Contact: Ph' ��: Cupertino Business License#:
Cht' ��s�o,✓a
Building Permit Info:
Bldg ❑ Elect ❑ Plumb r� Mech ❑
Job Description:
(NA-Ilw .e� P(-ic1,Mfar
Residential?12�M Commercial ❑
Cost of Project:
Strapped ❑ On Platform ,❑ Bonded
New Location ❑ Re lacement Z
Qty. i
A li Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
CITY OF CUPERTINO
Item 1 Of 8 PERMIT RECEIPT OPERATOR: Buem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36610135.00
DATE ISSUED. . . . . . . : 09/03/2003
RECEIPT #. . . . . . . . . : 23003
REFERENCE ID # . . . : 03090017
SITE ADDRESS . . . . . : 1682 JAMES TOWN DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HO GREAT P AND YA-JU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5315
RECEIVED FROM . . . . : HOT WATER INC
CONTRACTOR . . . . . . . : GUSLANI, CHRIS LIC # 21311
COMPANY . . . . . . . . . . : HOT WATER INC
ADDRESS . . . . . . . . . . : 2531 GRACELAND AVE
CITY/STATE/ZIP . . . : SAN CARLOS, CA 94070
• TELEPHONE . . . . . . . . : (650) 298-8494
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 23 .10 0.00 23.10 0.00
BPWHEATER PER HEATER 1.00 9.99 0.00 9.99 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
__________ __________ __________ ----------
TOTAL PERMIT 68.61 0.00 68.61 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•