05020035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CTOYIINFORMATIOM
r
BUILDING ADDRESS: HOT WATER INC 1111 NLb5020035
OW NER'S NAME: PERMIT ISSUE DATE
lip ONE: SANITARY NO, CONTROL NO,
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
u0C LICENSED CONTRACTOR'S DECLARATION JbDescription
w C 1 hereby affirm Net 1 am li¢vdn
uder provisions of Chapter 9(romo
mencing
tl with Section 7010)of Division 3 ofthe Business and Professions COOLS,and my license is
r,N L ensemeandeffecs r REPLACE WATER HEATER
5 vwj?
License Clan y Lie.N N
z Dale Com. r `i
J ARCHITECTS DECLARATION
1 undessund my plans.hall he used AS public records
is
o t; Licensed Professional
` 3 OWNER-BUILDER DECLARATION
Y 1 hemby affirm Nat I am exempt from the Conumots License Law for the
cc following reason.(Section 7031.3.Business astd ProfasdOt Code:Any city or county
X m� which m4uires a permit m conslmcl,alter,improve,demolish,m repair.1 moor m
az''a prior In its issuance,also mquiret the applicant for such permit to Glc asignd statement
that hcis licensed ptoononuo the provisions car the CO meter's Liccnx LAW(Chapmr 9 Sq. Ft. Floor Area Valuation
yFm (Commencing With Section 7")of Division 3 of the Business and Professions COM)or '
to that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant fora permit subjects the applicant in e civil penalty of 3 7AP343020erO 0 Occupancy Type
not mom dun fisc:hundred dollen(5500).
0 I,as wwna of the property,or my employees with wages u their sole compensation,
will do Ne work and the structure is not intended or offered for side IS".7044.Business Required Inspections
and Pmfesslons Code:The Conuactoh e ns
Law q p License w does not apply to an owner of
propeny who builds or impurities themon,and whodoessuch work himselfor through his
n employrss,provided drat such improvements arc not immnded or offered for mile.if, l '�'�1, ❑❑❑
however,Ne building or improvement is sold within one year of completion,the owner-
builder will hale the burden of proving that he did not build or improve for pur,ose of
sola),
El I,as owner of ct Properly.70Pk am exclusivelydd convecting with flared mnvactort to /j —�
constmct de project(Sec.]pea,Business and ProfeNons Codca 71rc Convactori Li� L/7/i'J f
cense law docs not apply in an Owner of property who builds or improves demon,and.
who contracts for such projects with a conuactor(s)licensed pursuant the Co rfactaYs '
License Law.
1 am exempt under Sec. .B&P C for this reazon
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby afRsm onder penally of perjury not,of the following declarations:
I have and will maintain a Cer ifiane Of Consent to self-insure for WorkersCompcn-
sstian,uprovided far by Section 3700 of the labor Code,for Ne Performanceof the
workforwhich this permit is issued.
CK have and will maintain Worker's Compensation Insurance,as rtyvimd by Section
1700 of Ne labor Code,for Ne performance of de work for which Nis permit is issued
My Worker's Computation Insurance carrier and Policy number amp y p!
CL ni,: I PUMA Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE
(This Section actl of hccomplc¢d if de permit is routine hundred dollars(SIR))
or hss.)
I eer iN Nat in the performance of the work for which Nis permil is issued.I shall not
employ any perwn in any mannerso AS to homer.subject to the Workcn'ComPcnsatiom
Isws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject in the Worker's Compensation provisions or the Inbar Code,you mum
.J O forthwith comply with such provisions or Nis permit shall he deemed mvokcd.
'Z CONSTRUCTION LENDING AGENCY
Ihereby affirm Oat Mom is a construction lending agency tar Ne performance of
a the work for which this Permit IS issued(Sce.2091.Civ.C.)
aQ Lenders Name
=,z lender's Address
U 0 1 certify,that I bate read this application and sum that Ne above information is
correct.l agree to comply with all city and county Ordinances and auto laws minting to
0U building construction,and hereby auNorine mpmenutives of this city to enter upon the
} above-mentioned pmpcny for hoecuon purpose.
(, gy (We)agree to rave,indemnify and kap harmless the City of Cupertino agars
U z lie`oliues,judgmenu.cosu and opuses which mey in any way.cosec agaittsaid City
in nsegarme of the granting of Nis pnmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL}}}NON POINT Issued by: Date
SOUrRCE�y EG^UL�A^nONS //,/�
CA, 1l,Ln `,-L-a-ear-.- /Y Re-roofs
Signature if ApplicaMCantractor T
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or Imodle hmardous material
ss dcfined by the CupenmO Municipal Code.Chapter 9.12,and the HCafth and Safety
CaY.Section 25532(.)? o All roofs shall be inspected prior to any roofing material being installed.
El Ya t
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamodous air contaminants AS defined by the Bay Area Air Quality Management all new materials for inspection.
District? ����
❑Yes IJN.
1 have mad the harardrmsmamrials re,,nioments under Chapmrd.95 of the Caliror
nia Health&Safety Code,Secuum,25305.25533 ad25514.l umkrmand Natifdc Wilding
docs trot connector hoc a¢nano Nat it u my responsibility m ratify de acupanl of the
reyuiscmcnmumbore tpdti toissnan«araeenirmaetirOcapaay. Signature of Applicant Date
Owner or authoriued Agent
.
O/ !/ r °ZLI
Dam All roof coverings to be Class"B"or better
Community Development
So,O
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
/�GSo Jvha � . Dr, oS02-0031r—
OWNER'S NAME: J Ju c/o / a 5B o PHONE # d8 - 7el/- 9'/2
GENERAL CONTRACTOR: f Wa / ,qc. FAX # SD
I am not using any subcontractors:
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 l7�f 14)a v 117C-
Roofing
/7GRoofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
amn WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN#
Building Address: U
/O /or.
Owner's Name: Phone#:
Q arca X08- 7(//- 9/zB
Contractor: // Phone: License#:
loses lo3/- 8yF Y, -70 3&
Contact: Phone: Cupertino Business License#:
C.ti & 3(- ayr7v a/ 3/, r
Building Permit Info:
Bldg ❑ Elect ❑ Plumb B� Mech ❑
Job Description:
Residential G]/ Commercial ❑ [ cJ 7—(- ,o /-z) F1<4f✓(Or
Cost of Project: 44- soo
Strapped ❑ On Platform Bonded 1-1New Location ElReplacement
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