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CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTORINFORMATIONN
BUILDINGADORESS:
HOT WATER INC
PERMIT N%5020039
OWNER'S NAME:
PERMIT ISSUE DATE
THOMAS HIN
ONE:
SANITARY NO. CONTROL NO.
(650)298-8494
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG °e f PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
H -r/1
lob Description
1 Wteby affirm Nat I am liamed under provisions of Chapter 9 (commencing
Sa6on7")of Division the Business Podheri ns Code, and my he.. is
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I&
with and
Onmnea�ander cot. C-`310
Lieenu C Lie. N
REPLACE WATER HEATER �a�
�
Dam Commcome ( r !l H C^®
ARCHITECTS DECLARATION
I understand my plans sM1all he used as public records
y COO
Licensed Professional
OWNER -BUILDER DECLARATION
(`C0
1 hereby ,(firm that I am Bumps from the Cssions o License Law for the
following mason. (Saito IDnsu Business and Professions Code: Any city county
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s
which requires permit to cmn6vucL alter, improv, demolish, m mask any structure
n
Orionmits issuance.also
ntor 00 the ainsam for such permiuofIcseLaw stammom
Out Laois licensed pursuant to the pro visions of thcConuumr i License Law(ChOOtm9
Sq. Ft. Floor Area
4'w Valuation
(commencingaith SansonBOB) of Division lnraleed Business and vilation of
that he u eumpt therefrom and the buss for the alleged exemption. Any violation of
3 56ffWQ3 etO0
Occupancy Type
Seotion TO] LS by any applicant for a permit subjects the applicant to a Civil penalty of
not mom than fila hundred dollars (S500).
0 1, as owner of Ne pmpcny, or my employees with wages as their rale compensation,
-
Required Inspections
will do the work. and theswctme is not intended or offered image (Sec. 7W, glumness
and Professions Code: The Convectors License Law does not apply to an matter of
pmpeny who builds m improves Merton, and who lea such work himself Cir through his
Own cmploycu, pmvided Nasuch improwmenu are not intended oroffered forsak. If.
however. the building or impmwsmmt is sold within ore year of completion. the owner.
Willer will have the hurden of proving that he did not build or improve for purpose of
.I.).
0 I, as owner of the progeny. am exclusively contracting with licensed conuutmrs to
connect the project (Sea 7064, Business and Professions Cade:) The Contractor's Li.
cense Law does not apply m an owner of property who Wilds or improves thereon, and
who contracts for such projects with a convanor(s) licensed pursuant to the Comramora
License Law.
0 1 en excmps undo sec. . B k P C for this reason
Groner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will moimain a Ceniftcate Of Consrnt ro self -insure for Wmker'sCompcn-
tion, as provided for by Section 3]00 of the Labor Code, (or the performance of thc
rrk for which this permit is issued.
d have and will maintain Wmkces Compensation Insmana, as requital by Section
la
Mof Ne Labor Code. for the pcnfomnance of thc work for whichthis permit is issued.
y Workers Coompe/nsatioonn Insurance amu and Policy numberarearnier:
,S �u�r C�ZI PC e'( Policy No.: I S yS�d tO
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecomplcted little permit is foronehundred dollars (SIM)
car less)
I cattily that in Oc perforrearteo or the work for which this permit is issued, 1001 not
employ any c sen in any manneres u to become subject to the WOnkerS Compensation
Laws of California. Dec
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become mhjcct to the Workers Compensation provisions of Oc Labor Code, you mut
forthwith comply with such prmisimss or this permit shall W doomed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that drem is a construction lending agency for the perrormana of
the work for which this permit is issued (Sec. 3097, Cih, C.)
Lender's Name
Lender's Address
1 cmily the 1 have read this application and soul that the above information is
-
correct. 1 agae to comply with all city and county ordinances and state laws relating to
Wilding consuunion. and hereby authorise tepreunu dives or this city to enter upon the
above-menuoned property for inspection purposes
(We) agar to save, indemnify and keep harmless the City of Cupertino alm
get
liabilluu.judgments,eosuandexpemowhichmayinanywayaccmoagaiw said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS
Re -roofs
Type of Roof
Signatureof ApplicanJConuacter Date
HAZARDOUS MATERIALS DISCLOSURE
Will IW applicant or future Wilding occupant store or handle huardous material
u defined by Oc Cupeninm Municipal Cod, Chapter 9.12, and rhe Health and Safety
"
Colo. Section 265320)?
All roofs shall be inspected to any roofing material being installed.
[DY.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fuum building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Asa Air Quality Management
all new materials for inspection.
District /
0 Yea $Nu
1 have sad the Waardtms materials rcyuiremcnu under Chapter 6.95 of the Cxlirm-
mAHealth &SafctyCrek. Sections MY)5,25533 and 25534.1 undersand the ifmc Wilding
Jas not currently have a ¢rant that it is my,apo 'hility w notify the occupant of the
ayuimmust Wmet prix riaap err. cmmfieate mr� ey��
Signature of Applicant Date
I'l .f�� %�
All roof coverings to be Class "B" or better
Owner
or authmrivad,gem Dam
mo
CRY OF
�UPEkTINO
JOB ADDRESS:
e10 qio r
OWNER'S NAME: Tf oma s
GENERAL CONTRACTOR:
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
uilding De artment
PERMIT #
O S ,
64>2
ke/.na vi PHONE # yoff- 953 - F
Vo l //7,-, FAX #
I am not using any subcontractors:
Signature Date
Please check avohcable subcontractors and comvlete the following information:
Owner/ Contractor Signature
Date
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
Tile
Owner/ Contractor Signature
Date
•
•
WF
CUPEkTINO
CITY OF CUPERTINO
WATER NEATER
PERMIT APPLICATION FORM
APN #
�l q
Date:
Building Address:L7
4
PLUMBING
Owner's Name:
Ern
Phone #:
yo? -ds 3 -,'7B7
Contractor:
�f �,/a-f-er
Phone:
License #:
-7&3(n/,P
Contact: I
C rk-S 6
Phone:
Cupertino Business License #:
-k
us -la to S0-G,3l -8 vsy
Building Permit Info:
BldgEl
. /
Elect El Plumb Lam'
Mech ❑
Job Description:
.
��ciLQ_ 7ilJCefCJlr �� ✓^ 51L (5 /J7 / G /LP
Residential
Commercial ❑
l t 0 fD �e—X �e r/D/'
Cost of Project:�O
Strapped ❑ On
Platform ❑ Bonded ❑
❑
New Location
Replacement
Qty. if
Applicable Fee ID
Fr+c 1`) cr,;nf;,.
U-- n_
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING