04010059 CITY O>'cOPERTINO
a
BUILDING DIVISION PERMIT CONT"C-TOR INFORMATION, a
BUILDING ADDRESS: HOT WATER INC 1E11ITN004010059
OWNER'S NAME: PERMIT ISSUE DATE
BRUCE K EI4'1
ONE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
_00 LICENSED CONTRACTOR'S DECLARATION I lob Description
P 1 hereby affim that 1 am licensed under provisns ioof Chapter 9 bcnmmencing P
n�Or with Sadian 7000)of Division3 ofthe Businessand Professions Code,and my licens.is
e. in rail mree inn erre. WATER HEATER REPLACEMENT
clpr /� r1 I—�
LIL.N a u \LIED
Z F° Datc N010VL4�
j�ujARCtI1TeC"DGCLARA ON
I understand my plans shall he used as puhhe records
U
FEB 1 9 2004
e'y License)Pmfesxinnal
ce OWNER-BUILDER DECLARATION
s S 1 hereby affirm that 1 um eamnpl Rom the CmJmchars hiccvc Law fur the �fI ft��D���
p O fallowing mason.(Section 7031.5,Business and Pmfe.¢iuns Cade:Any city or county O U
K m E which requires a permit 1.ennxtrucl,alter,improve,demolish,or repair any structure
Yea prior m its issicnc..alsa requires the applicant forsuch permit to file a signed Statement
£x that he is licensed pursuant LO[tic lutwismasofflace,Comunctor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
(eomingwllhSeelled70NP.[D,ia.n 3 nfthe Banumssamfos
l prosiuns Code)m
i That be is mencexam Pl Ncafram and the haus for the alleged exemption,Any violation of rars�wi�r..r.e...�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Family Of 3510`2 YW1 Qr00 Occupancy Type
not mare roam Eve hundred delta.(SIDE). P Y YP
❑I,az�wner.f tla progeny,or my cmplOYcea wit wages as their xnlc cnmpcnsalinn,
will do the work and the suumum is not intended uroffered for sale(Sec.7044,Business
and Professions Cade:The Commences License Law dues not apply m an owner of Required Inspections
property who miles or improves thereon,and who doeeeuch work himaelfor through his
own employees,Ouvided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,to Owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
1,as owner of the property,am exclusively contracting wit licensed contractors to
construct the pmjccl(See.7044,Business and Professions Code:)The Commerce's Li- .
cense Law does not apply to an owner of propeny who builds or improves thereon,and
who contracts for such projects with a contrachON)licensed pursuant o the Contractors
License Law,
I am exempt under See. B&P C for this rased.
owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will m ai main a Cenificam of Consent to sel f-insum for Worker's Cum pan- -
salion,az provided for by Section 3700 of Ne tabor Code,for the pedmmmnce of the
work for which this Permit is issued,
KU0have and will maintain Wnrker's Compensation Insurance,a required by Section
of ON labor Codc,for the performance of the work for which this permit is issued
My Worker's Ci mpeer sattiion Iniu ince carrier and Policy number
raam �r �y�.fs
Carrier: S�'1 1��Us1) Policy No.:_ /�8 T r _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is forane hundred dollars($IND
or less.)
I cenify that in the performance of the work for which this Permit is issued,1 shall not
employ any pm e.in any manners.as to become subject n the Wnrkeri Ccom ansmimi
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cemilieae of Excmpli...you should
become subject to the Worker's Compensation provisions of the Li Mn Coca,you must
z forthwith comply with such provisions or this Permit shall he deemed revoked,
'Z51 CONSTRUCTION LENDING AGENCY
'rt sIhereby
Name affirm Nal Ncreis aconswninn lending agency l'arthe performance of
p: ?
CITY OF CUPERTINO
1.-' WATER BEATER 0
CUPERTINO PERMIT APPLICATION FORM
APN#3 23 Date: D/
v O
Byy,ildinAddress:
Owner's Name: Phone #:
blLuc 12J09) ZSs�--
Contractor: P n'e: License#:
Contact: P Cupertino Business License#:
0-04,s Gulc�y �Sa cP
Building Permit Info:
Bldg ❑ Elect ❑ Plumb gz� Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: e
S 00
Strapped ElOn Platform ❑ Bonded ❑
New Location ❑ Re lacement CJmm
Qty. if
A ]ica le Fee ID Fee Descri tion Fee Group
BPWHEATER Water Heater/Vent BUILDING
l \ PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING