05010133 BUILDING DIVISION PERMIT CONTRACTOR INFORMATIONi
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BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NCO 5010133
.20071 LAS C)NT)Aq WY
OWNER'S NAhIE: PERMIT ISSUE DATE
Adkka BETSY MILLER 970 E . MAIN ST SUITE 200 01/24/2005
ONE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
10, LICENSED CONTRACTOR'S DECLARATION
u❑ hereby ereby affirm Ilial 1 am immed under provisions or chapter 9 kommeneing Job Description
fou with Section 7Wffof Division 3ofthe Businessand Prufmori Code.and my Heave is
in full form and er{� G REPLACE WATER HEATER
Liccnsc Clpa,. —�-�Lic.p
H p Dam s f/-�/sJ� Cuntracmr RT
ARCHITECTS DECLARATION
fz< I understand my plama Atli he used As pamiereenrds O
u,t, Licensed Professional
S OWNER-BUILDER DECLARATION
<y I Worry affum Nal I am exempt From the Contractor's License Law for the
-00 following mason.(Schon 7031.5;Business and Pmfcxviotts Code:Any city or county
<m which requires a permit In construct,alter,improve,demolish,or repair any structure $900
?iy prior to its issuance.alsu requires the applicant for such Permiuu file asigned stammcot
< that he islmosedruminant otheprovisionsortheCommcwriLianuhw(Chapter9 Sq. Ft. Floor Area Valuation
e1-0 (commencing with Section 70f10)of Division of the Business and Prorcasions Code)or
$ that he is exempt thcmfrom and the boos for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to acivil penalty ofer0 0 . Occupancy Type
not more man live hundred dollars(ssuo). PanC Y YP
0 1,aS owner of the propcny,us my employee with wages as Nei,sole compensation,
will do the work,and the stsucrose is not intended or offered for sale(Sec.7014,Businea
And Professions Code:The Conmctor's Liaoe Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvement are not intended or offered for sale.IL
however,the building or improvement is sold within one year or completion,Ne owner
builder will have the burden of Moving that he did not Wild or improve fat purpom of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed connectors to
construct the pmjed(Sec.7W4,Busineu and Professions Code)7Te Contractor's Li. .
come Law does not apply to an owner of progeny who Wilds or improve:demon,and,
who contract tot such ptojecu with a contrarsonts)licensed pursuant to the Cortractorb
Licese nLaw.
(]1 am exempt under Sec. B&P C far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby off rte under penalty of perjury one of the following declarations:
I bare and will maintain a Cudriam of Conant to self-insum for Worker's Compere
137,00
ion,u provided for by Section 37M of the tabor Code,for the perfannana of the
rk for which this permit is issued.
I have and will maintain Workcri Compensation Insurance u required by Section
of the tabor Cade,for the performance of Ne work for which this permit is issued.
Workersrn '1 'l '''yrtier: /m '/ ` " — Policy No.:S (9'O T�U/-7/
CERTIFICATE OF EKEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(ITIS section need non be completed if the permit is for one hundred dollars(1100)
or less.)
I eenify that in the performance of the work for which this Permit is issued.I shall not
employ any Person in any manner m o to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should .
become subject to the worker's Compensation provisions of Ne Labor Code,you must
z forthwith comply with such provisions or this Hermit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm Nat them is a mnnmClHm lending agency for the performance of
x me work fur which this permit is issued(Sec.3097,Civ.CI
37 � Lender's Name
3.
3 z Lender's Addreu /
J� 1«nee o c 1 have read this applicationandordinances sine tet the stove woe mating is
Z) buildin 1 agree Ir comply with all city end courtly 2iveSOf and Cute laws rebating t e
OU buildingconstruction,proend hoebyauthoniaerposes. ttivesofNis coytocorerupon the
ahovc(W)agree
progeny fin inspersion lecell purposes.y y (WD)agmen(nun.indemnify and keep harmless the City of Cuyenst s against v
Z liabilities.PCC ethCgrstandexpenxeswhich may in anyway eeervc against said City L
J z to PLIC NT Dnbc WSTA�ntis Dnhia D WJ Issued by: Date
APPLICANT UNDERSTANDS AND w L COMPLY WITH AL ON-POINT
SOURCUL' ON /� /
�[— , f9'V 0S Re-roofs
Signature of ApplicanUCo ecbr Dale
HAZ RDOUSMATERIALSDISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havarduus material
ax de rod by the Cupenino Municipal,Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?
Ve All roofs shall be inspected prior to any roofing material being installed.
Ij]Nn^
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hurardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
trirs7
0Ycs Isf4�
1 have mad the hanooms mammials requirements under Chapter 6.95 of the Califon-
niaGum&Safety Calc Sceuau25505,25533 and 25534.1 undctuand thatifthe Wilding
does not curcndy has a enanL Nat it is my espovibility m noufy tie upon of on
equiemcnu whicM1 cin poor to into c f ACcrufealc of Ocin army.
-17 au�0 S Signature of Applicant Date
Owner tar authorimd agent Date All roof coverings to be Class"B" or better
. PTY
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
F Fax(408) 777-3333
OUPEkTINO
Building De artment
JOB ADDRESS:z O 6 , ` 1 p PERMIT #
lin cY 0go1o133
OWNER'S NAME: PHONE # 4 4(o -2 f �
GENERAL CONTRACTOR: ot1t,, ghj:tjFAX #
� Qs.
I am not using any subcontractors: F �P� - @0jL 4ea
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
11 Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tiler (�
l-zzL os
Owner/Contractor' Signatur Date
CITY OF CUPERTINO
amt WATER HEATER o Ste' " L�3
CUPERTINO PERMIT APPLICATION FORM
APN# 43/ 3 Z 03 o Date: / a y /p J
Building Address:
aZ OU ? I
Owner's Name: Phone#: 41L16 - -2171
Contractor: /� o License#:
!v F,)(435-5546 3 -7 Y 5 7 3
Contact: Phone: Q Cupertino Business/License#:
� w A
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: 1/ 0.0 w Q_
Residential Commercial ❑
Cost of Project:
q,;762. LT-D
Strapped ❑ On Platform Bonded ❑
New Location ❑ Replacement ❑
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
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