04110001 CITY OF CUPEW11NO
BUILDING DIVISION PERMIT CONTRACTOR`INTORMA'CION F
BUILDING ADDRESS: KIA CONST. PERMIT NO.
04110001
O W NF.R'S NAME: PERMIT ISSUE DATE
34
ONE: SANITARY �Atll.NO.
ARCHITECUENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
0
Loo
LICENSED ONIRd under provisions
DECLARATION
iaF IherebyaffirmtbmIemliaeBuunderndPrfessofChapter 9(commencing Job Description
t`$ with Rem,,iondle)ec Division 3o HC Business entl Professions Code.and my license is
n a
in full fo¢e and effect.
nq'i License Class Lim.x REPIPE/WATER HEATER
Z"� Dam Contractor
AROBTEC'S DECLARATION
?wU Profe and my plans shall he uxJepublic records
30G Licensedd Pmlcssinnal
So
OWNER-BUILDER DECLARATION
<q I moth,affirm Hot 1 am exempt ffom the Comomm's License Law.for the
$ which
yrcyuires a 00 following mason,(Section 7031.5.Business and Professions Code:Any city or county
k permit ,,construct,niter.improve demolish,or mpoir any emend.
Fiy pAonn its issuance,alw requires the applieam forsuch pertniuo tilt asigneJ summem
Fz0 that he is licensed pursuanuothe proviamea fUnControchasLicenxLaw(Chapter9 Sq. Ft. Floor Area ValuaL O
tat- (commencing with Section 7")of Division 3 of the Business and Professions Code)or
US
Net he u exempt tWmfrom and the basis for the alleged aaamption.Any violation of
Section)831.5 by any applicant for a permit subjects Ne applicant to a civil ria Penalty of
not mem than a hundreddollars($5W), y 3_9Vy1IlpJ gr00 Occupancy P Y Type
0 I,u owner of the property,or my employees with.,as as their in compensation.
will do He work and She swnure is not intended or offered for sale(See.7014,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who buildsor improves Hereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered(orale.If.
however,He building or improvement is sold within one year of completion,He owner.
builder will have the burden of proving that he did not build or improve for purpose of
`�sa✓l;1".).
Was owner of the property,am exclusively conua0ing with licensed cantm0ors tp
constrain the project(Sec.7044,Business and Professions Cade:)The ConuaOor's Li.
cense law does not apply to an owner of properly who Wilds or improve thereon,and
who contracts for such projects with a eomracmr(s)licensed pursuant to the Contractor's
License Law.
0 l am exempt under Sec. ,B h PCfUS, a on
Ow r Date
73InsYORKER' 1P, SATION DECLARA N
I hereby effrm set er�na77 perjury one of tlm fallow selandrian
I have and will maintain a Cenifmatc of Consent ro self-insum for WorkersCompcn-
urance40
wn,as provided for by Section 3IW of He Labor Code.for He performance of the
ork for which this permit is issued.
1 have and will maintain Worker's Compensation Insuance,as required by Section
of the Labor Code,for He onf ma ass of He work(of which Hpermit Shia peit is issued.
My Workers Compensation carrier and Policy oumMr aa:rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not he completed if the permit is fomite hundmd dollars(SIW)
m less.)
1 certify that in the performance of the work for which this permit is issued.1 shall nut
employ any persan in any manner sit as in become subject m the Workers Compensation
Laws of Cali faros..Data
Appimsnt
NOTICE TO APPLICANT:If,after making this Ceni esto of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
z foMwlth comply with such provisions or this Permit hall W deemed invoked.
z CONSPRUCr1ON LENDING AGENCY
F Ihereby affirm that Here is a construction lending agency for the performance of
CC� He work for which this Penn it is issued(Sec.3W7,Civ.C.)
41]A Lender's Name
z Lenders Addrecs
U C) I certify Het 1 have read His application and sure Net die shove ammouiun is
Fcorrect,l agree to comply with all city and county oninances and state laws relating tet
0U building construction.and hereby Ontario,reprommadves of this city to enter upon the
snow:-mentioned property fon inspection which may
H C (We)agree m cave,indemnify and keep harmless the City of Cupenino against
Z in
(therangrantintandg
expanmsmay in any way acerae againstSaid City
f>z inconsCAN'Tc ofthcgranting Df this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.-P INT Issued by: Dat
�SOURCE REGyU�L,�10
//1 � '2iy Re-roofs
9motioao pit U on trach.
IIAZAR MATERIALS DISCLOSURE Type of Roof
WIIl the apPlicam more building wcupnm score nrhannc hmanous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Con,Section 25532(a)?
0Ye No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use noopmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mit haardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? a.
O Yes No
1 have read the ha an ono`s materials requimments under Chapter 6,95 of the Califon
iia HcalthASafcryCndc,Sections 255115.255]3 md25534.1 undcrsund Hvt iftW building
docs not curta ly bane a tenant Natmy rcspnmihility to nodly tM occupant of He
myvimmc� nm stWmet pdnr an cendaatc or Oeaapan y. Signature of Applicant Date
ow er
an.d li,min4z All roof coverings to be Class "B"or better
RLI®®e
CITY OF CUPERTINO
WATER NEATER
CUPEkTiNO PERMIT APPLICATION FORM
APN# � � � Date:
Building Address:
�j S eyt7Lrios ,�j� %J v/
Owner's Name: Phone#: O
CJ ef V 77
Contractor: ,( , hone: License#:
Contact: Phone: Cupertino Bu5 iness License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb, Mech ❑
Job Description: �Y�� tom, �la'7� lof�elll
Residential ` Commercial ❑
Cost of Proie t:
Strapped On Platform Bonded ❑
New Location ❑ Replacement
Qty. if
A pf I ab lit Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License 13UILDING
1