03060143 CFPY.OF CUPER•fINO a ,r �C ' vs <i TA
BUILDING DIVISION PI✓RMIT 'CONTRACTOWINFORMATION
w, 'iac'r
BUILDING ADDRESS: TOM' S PLUMBING PERMITNO03060143
a OWNER'S NAME: 12246 SARATOGA SUNNYVAL R YERIvIFIISSUBDATE
N@t (408) 867-6010 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o. 0 0 0
100 LICENSED CONTRACTOR'S DECLARATION Job Description
CC ❑ I hcreby efrom that 1 am licensed under provisions or Chapter 9(commencing P
<ZW with Section 70018 o(Division 3 ofine Busi and Pmfesdnm Code sad ylioc.,.a
<ow mmBm derreM. 222 9 & REPLACE WATER HEATER
�ViZ Liunx CLI.N �y/Ip
J Date��� /o.� o Cunu surCee
II tl 151 Jj
eq y ARCIIITECI'S❑ ATIO ll� d'1s
e a I undersand my plans shsll he used u pu c AMcords [�
W JUL
y�
Licensed PnsfcsaioAULnel g? 900
3 Oat I am eUHAE0.m Ce Contractors
ON C
C 0 2 hcwby.(Sean ons 11. exempt s an d r Contrns Co License Law for the
O O following reason.Permit
t ] Business end n,de am Code:Any city m county
$ which tits is s v permit 70 construct.the
pitch Impmw,demolish,or repair ed structure I L�
thaibeprior itaissusdpub also
anito ds thovisioeam dic for such Convermiuofile aicense aw(Chtemcm
¢¢ < oat Amiscing ithSection70t�pmviviomrfortheBuiness License (Chapter Sq. Ft. Floor Area IuatlQn -
Y $ (cat he Is
(commencing therefrom
and of basis for
oftheeged exeand
on.Asinnd Cndc)tar
mat he b exempt ahenfmm end the bsia far de alleged exemption.Any vinla6on of 34214032 . 00
Section 7031.5 by any applicant fon pennissubjeeta the applicant to a civil penalty of APN Number Occupancy Type
nm marc Non Ban hundred dollen 0500).
[11.it owner of the pmpeny,or my employees with waged at their in compensator,
will do the work and the sanctum is not imendedo.(fined hotels(Sec.7014,Business —
and Profesiam Code:no Consacims Liecox Law dao not apply to an owner of S O 6 — GAS T C
OPKU
progeny who builds or improves thereon,mod whodas such work himself or Ihmugh his
own employees,provided that such improvements arenot intended oraRered for sale,If, 507 — FINAL PLUMBING
however,Ne building or improvement limit!within one year of completion,the owner.
builder will have the burden of proving oat he did not build or impww for purpose of
s1,1
❑1,as owner of the property,am exclusively contracting with licensed contractors to
constrict the project(Sec.7004,Business and Professions Code:)The Contractor's Li.
come Law does not pply to an owner of property who builds at improv,thereon,and, .
who contracts for such projects with a contractor(a)licensed pursuant to the Conaraam's
License law.
❑I am exempt under Sec. •B k P C for this recon
owner Dam
WORKER'S COMPENSATION DECLARATION
1 mroby of lne under penalty of perjury ane o(ahe following decdan0am: -
1 hsw and will maintain a Ceniftcne of Consim w sel5lmure fa Wortrr's Compen.
saurian.u provided for by Section 37M of the labor Code,fm the perom uce of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Imurance,s myuined by Section _
3700,the labor Code,for the performanec or the work for which this permit Is issued.
My Worker.Comte nit m�na cvrrirrend Policy numberam:
Ca 'ere s �uL-G✓//Policy 0� 0
CERTIFICATE OF EXEMPTION FR WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If she permit is form=hundead datlm($100)
nrku.)
1 unify that in me performance of the work for which this Permit is broad.I shall not
employ any person in any manner an at to become subject o the Workeri Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT,IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions or the Ichor Code,you must
,J ,z (oMwim comply with such provisions ar this permit xhall be deemed wvoked.
z O
CONSTRUCTION LENDING97. .)
E" NCY
I hereby a(ftrm that dere is a conduction lending agency lot the performance of \�--
W the work for which this pemtit h(sued(See.709],Co.Clv.C.I
W
Q 1<nder's Name
.7. z Lcnderi Address
U O 1 canify that 1 have read this vindication end state that the shout inrormuian is
IyF correct.l agree to comply with all city and county ordinances and sate laws minting to
. building construction.and herew
bydadon for mseMbivcs of this city m enter upon de
-�C.7 - -
T' aohove-mcmioned property rat inspection purposes.
(We)agree to an.indemnify and keep harmless the City or Culemino against rl
wfn liabilities.judgments,case and mpcmaccrue against which may in any way accragainst midCity (/
V zs omit.
APPLICe.1'the gractint of UNDERSTANDS t
AND ND WILL COMPLY WITS ALL NON-POINT Issued by: Date
SOURCE REGULATI S. 3
ty, 14'P Re-roofs
Sign re of App anUContrwsor ale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stow or handle hasrdous materiel
as dc0ncd by the Comma.Municipal Code,Chapter 9.11.and she Heabb and Safety
Colo.Section 25532(,)? All roofs shall be inspected prior to any roofing material being installed.
0Yo 1ANW
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 hmardnus air contaminants s defincd by the Bay Area Air Quality Management
'win? all new materials for inspection.
❑Yca (06
I have mail the hanNtms momrisb wquiremenu under Chapin 6.95 of the Cairm.
ria H..10 A,Safety Cndc.Saud.25505.25537 and 25530.1 understand my if the building
dos not currently ban a tenant,that it u my respomihiliay to notify the occupant of the
w4wwmeatawhich musto metpdar tied eeof.CemRcateor0xinaney. Signature of Applicant Date
V 9zy.,��its• 6,Zy—4,
owne rG una'eaagmnt �;tm All roof coverings to be Class "B" or better
aawo
CITY OF CUPERTINO
WATER HEATERCUfTINO PERMIT APPLICATION FORM
APN # J —0 j y� Date
Ad
Buildin dress:
j0N I La ��w000/ 17�
Owner's Name: Phone#:
C',MPg2on�, ZS`5- 5 kH
ConntractorPhone: License#:
PtL1 ( c,�&7
Contact: Phone: Cupertino Business License#:
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Building Permit Info:
Bldg ❑ Elect ❑ Plumb a Mech ❑
Job Description:
<I-C a .• rf-Ae
Residential (®" Commercial ❑
Cost of P ojec:�S
>71
Strapped On Platform Bonded
New Location ❑ Replacement
Qty. i
ApplieaWe Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING.
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
�Z2� 6