04110090 CITY OF CUPERTwo CONTRACTOR INFORMATION:
BUILDING D{vlsloN PERMIT * a, ,_r,�._
BUI LOINOADDRISS: HOT WATER INC PERMIT N%411O090
22270 KENDLE ST PERMITLSSUEDATE
OWNER'S NAME:
04
BRAD SARGENT 2531 GRACELAND AVE 16 20
SANITARY NO. CONTROL NO.
ONE:
(650) 298-8494
BUILDING PERMIT INFO
ARCECT/ENGINEER: BLDG
HITELECT UMB PLLMECIi
t� (�
LOo LICENSEDCONfRACTOR'SDECLARATION Job Description
G I hereby affirm thn 1 am licensed under provisions ofChapterCcW,r 9(commencing
r� withsf Me
efficDivision3arN Basin.a �Jncair d-(lice"aria REPLACE WATER HEATER.
in mu fame ata erre ,3lJ Lk.X
�z License Class
zip Da¢ Cumncmr -
W1 CT
ARCH] DECLARATION
�.a I understand my plans shall M used as public records
,aD T(/� ✓
3 u N Licensed Professional
a<
OWNER-BUR-DER DECLARATION
ef I hereby affirm that 1 am exempt Bum Ne Commnors License Law for the
d p O following mason,(Section 7101.5.Business and Professions Cast:Any city or county $500
m� which¢,airs a Wntit m counme,alms,improve,demolish,or repair any awnuo
zv, rano ioiuissuantt,steer(quirsnMapplicant forsuch Wrminohle¢signed nammcm Sq,Ft. Floor Area Valuation
—< Nal he is livcnud pursuanuntl pmvisions of the Cnnaaetori Liecnsc law(Chapter9
9 (commW0l(commencing with Section Bof Division 3 or the Businsxand Prureminns Code)or
Nu ha is asmpl therefrom it Ne basis Tor the alleged euer,olm.Any vmodan of
Section 7031.5 by any applicant far a permit aublecu the applic im m a Civil penalty of a Occupancy Type
not mom than Hire hundred dollars($50%
1,as owner of the property,or my cmploycu with wags as their sole compensation,
will do the won,and 01awaureisno,intended uoffered(or sale(Scc.71Na.lboh,-a Required Inspections
and Professions Code:no Contractor's License Law docs not apply m an owner of
property who builds or improves thereon,and who it.such work himself a,through his
own employees,provided Nat such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have Ne burden of moving that he did not build or Improve for purpose of
sale.).
1,as owner of the progeny,am exclusively contracting with licensed conracmrs to
conswci to project(Sec.7Bad,Business and Professions Code:)The Co"oacor'x Li-
come taw Lens not apply man owner of popery who Milds or improves Moment,and.
who contracts for such Pmjecu with a crunu n no)licensed pursuant m the Canaanors
License Law.
❑I am exempt under See. ,B&P C for this rescan
OwnerDat
WORKER'S COMPENSATION DECLARATION
1 bereby a1B.under penalty of perjury one of Ne following declaraions:
1 have and will maintain a Cenifcatc of Consent in self-insure for Worker's Cempen-
saion,as provided for by Section 37M of Ne LSM,Cade,for Ne W rformanco of Ne
work far which this permit is issued.
[�'1 have and will maintain Worker's Compensation Insurance,as required by Sceunm
59(18
Mile Labor Cade,for Ne N formanee of the work for which this Wmtit is issued.
Ca fie'. s omlonmtion Ins ko,fier and Polity num Mr am:
Cartier. �( Polity oUl 5�6
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This union need not be completed lithe permit is formic humlmd dollars($100)
r less.)
1 certify but in Ne performance of the work for which this permit is issued.I shall nut
employ any W rson in any manner so so as hemme subject to the Workeri Compensation
Laws of California.Date
Applicant p should
NOTICE TO APPLICANT:If.after making Nmstunis Ccnificac of Eac ,you
become subject to the Worker's Compensation provisions of the Lehr Code,you mon
.J Z forthwith comply with such provisions ar Nis permit shall M deemad revoked.
ZO CONSTRUCTION LENDING AGENCY
I hereby a oro that there is a construction lending agency for the perfarman c of
[Ya 7 Ne work fur which this permit is issued(Sec.301 Civ,C.)
W QLenders Name
7 z Lender's Add..
J I Moify Nn 1 have mad this application and state that the above i"from anus is
W F correct.I agree to comply with all city and county modro noes and sole laws miming m
nd
y to
0O building constitution,)., Iane,outran
fy said keep
MMMT representatives OfCuprtir upon no alsolo
r W shove-memicned property far ispecuon puryaua.
11 (We)ague m save,inJemmfy and keep harmless w City Of Domains,id City
In liabilities,judgment,casts and expenses which may in any way ettmc against said City
U in conarqucnce of the grand ng of this Permit. Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLL/,NON-POIINNT Issued by:
SOUSOU Ey � / I(//fG 04
tiLriu�l C�h�-d2�1,r � Re-roofs
Signature Of ApplicaMConuaco, Orem Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
WIII No applicant or future building occupant atom or handle W.Wmus material
as defined by the Duration,Municipal Cade,Chapter 9.11.and the Health and Safety
,MLcWc.Seem On 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
Ycs ANO
Will be it"liaam or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit Wilmons air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
Disuict7"., gco
.$,��
Y ^l Ne haaNnua materials o"MM' /Ole
ty Code,Sccdus 15505,15533 and 25536.1 undxuNnd Nair'the MlilJing /,1 ' ' ^y haw a tenant.Nat it u mY mat c rcmupant ocbmmnMmet Ourmiaxcanalap y. Signature of ApplicantDate
� IAll roof coverings to be Class"B" or better
risJ agent am
aClOF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEI TING
Building Department
JOB ADDRESS: PERMIT #
aa- d -70 /fid/�
OWNER'S NAME: lar n t✓ PHONE # 0 30-
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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 ! 1 tNc�fe✓ /n C ( 3/
Roofing
Septic Tank
Sheet Metal
Sheet Rock
/ Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO o a o
WATER HEATER 11
® CUPERTINO PERMIT APPLICATION FORM
APN # 3 Date:
Building Addrea d -I o 1/ SCI
Owner's Name: �C Phone k
Contracto( Phone: License :7c0 30(�—
Contact: Phone:4 Cupertino Business License#:
LJk rt-5 (z /aVlr i` " 3 /
Building Permit Info: — /
Bldg ❑ Elect ElImo
Plumb ' Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: 5
Strapped ❑ On Platform ❑ Bogded ❑
New Location ❑ Replacement [ /
Qty;,if
A licable. Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING