05120096 CITY OF CUPERTINO 4wA;s 4i e
BUILDING DIVISIONPERMIT "CONrRAC�T,,OP,�INFORMA-TIp
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.05120096
R R s; LONNA IN
OWNER'S NAME: PERMIT ISSUE DATE
1h
GAIL & FREDERICK EATOCK 970 E. MAIN ST, SUITE 200 12/15/2005
SANITARY NO. CONTROL NO,
(800) 835-5946
ARCHITECTIENC[NEER; BUILDING PERMIT INFO
ELECT PLO
LMECH
30o LICENSED CONTRACTOR'S DECLARATION j
red I luenclay affams,that I am limmed under provisdars;of Chapter 9(commencing Job Descri5tiof(f I
with Section TOW)ofDlvlsion 3 of the Business and Profession&Code.and my license is �410z
"" 'a�yand e�
u _3- LI
-tS7 REPLACE WATER HEATER
V4L! LLoF *Dc Cn"c ,
ARCHITECTS DECLARATION I
I uracknumad my plans shall be used As public acconds
g6t; Licensed Professional
gI hereby arrant'j OWNER-BUILDER DECLARATION
hat I am exempt from the Contractor'.License Law for the
ECO following ressaft.(Sod "7031.5.Business and Professions Cole:Any city"=my
which rtq.t.A permit to construct.Alan,Improve,demolish,or repair mtruct
Any sure $900
lira priorto its issuarma,also requires the applicant fwauch Knoell to rile a signed sunnument %2
that m 4 limmed pursuing to ft provision or ft Commastat's Limme Law(Chapter 9 Sq.Ft. Floor Area anon
(commencing with Seems 7000)of Division 3 of the Business And Profession,Care)or
Net he is exempt therefrom,and the looks for the alleged exemption.Any violad on of
Sector 7031.5 by any Applicator,far a iminsit subjecu;the Applicant toe civil penalty of Occupancy Type
not..does Five hundred dollar.($500).
0 I..amen,of the property or my employees with wages As Net sole comimmichan,
.ill 0 the",it,end ftmacture hoot intended or offered for sale(Sec.7066,Business
and Professions Code:The Comsecton's Licence Law does Out Apply us an Owner of Required Inspections
property who builds or ire proves chances.and who docs such work himselfac through his
Own employes.provided that each improvements Am not intended motional forrule,If,
beausevcr,the building or Improvement is sold within am year ofcompledon.the Owner.
builder will have the burden of proving,that he did Am build ar improve far purpose of
sale.).
0 1.as Owner of the property am exclusively convecting with licensed anoamors to
construct ft Project(Sec.706x,Business,and Professions Cods:)The Contracessn's U.
came Law does not Apply m an owner of property who solids or improves themon,and
who contracts for such projects,with a contractor(s)licensed Personal to ft Contractun',
License Law.
0 lamexemptunderSec. .B&PCf.LhIsmmOn
Owner
Data
WORKERS COMPENSATION DECLARATION
I hereby&Mm under Penalty of perjury arm of ft following docarationc:
I ba.and will amirmia A Certificate of Cannot An seff-miners:for Workers chosen-
-a..
as provided for by Section 3700 of me Labor Code,ror ft performance of the
work for which this Permit Is Issued.
I have and will maintain Worker's Compensation Insurance.ax required by Smdem
110.1'the Labor Cade,far me performance of the Areas,l4which MIA Permit is Issued.
M IyWorl'Works' Com a��=CaMsrsndf`olic,nunmsc
Policy NoV�j_�T'xt503-013
Car .
C TIFICATEOF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
mis section need net be completed if de punall Is forma hundred dallant($1,M)
or[a=)
I madly that In the perromance of the work fm which dhIs parml,is issued,I¢hall not
employ any person in my Attract an as A,became wb*i to ft Workers'Compensation
Law.of California,Dam
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subjesn to the Workers Compensation provisions of the Labor Code,you most
Z forthwith comply with such provisions or this permit mail the deemed revoked.
z 0
E M CONSTRUCTION LENDING AGENCY
I hereby affiren that dams is.construsion lending agency for me performance of
ft watt far which this Permit I.Wood(Sec.3097.Car C.)
A
L.dr's Name
CL,
Z)z Londer'sAddreat
U 0 1 certify that I have scaut this Application and law that the Above infoartation is
O. Combat.I agree to comply with all city and county andausness and&am lam relating to
0building construction,and hereby autbodau rophommatim of this city in enter upon ft
U shove-mentioned property for inspection purposes.
Q� (We)agree to saw,indemnify and keep harmless the City of Cupertino against
or) liabilities.judgments.mats and expenses which may in any my amus against said City
in consequence Of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE REGI�.�Tl N . lz-/1
_V 5/05
_ Re-roofs
Signaturs,ol'Applicarso'Contractod Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building OCCUPIRLSIOTO or handle hummult,material
as;defined by the Cupernme Municipal Code.Chapter 9.13.and the Health and Safety
Cade,d' Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
CY. O&�
Will the applicant or future building Occupant or equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
e.olthusadmas alt conuartimunts sa dalmod by ft Bay Are.Air Quality Management all new materials for inspection.
District?
0 ye.
I ban mad use Ismandicaus materials aniumancrus under Chapter 6.95 afore Califor,
at.Health&Safety Code,Sam..25505.25533 and 25331,1 understand ft If the building
does not manually haw a anam,chs it is my memorably in wall,ft=opm,of ft
Signature of Applicant Date
Owner or mthai nt Dow All roof coverings to be Class "B"or better
Community Development 9
10300 Torte Avenue
z Cupertino CA 95014
' f Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
IIPER,TINO
Building Department
JOB ADDRESS: / PERMIT # /
OWNER'S NAME: PHONE # 'Vff 6 -p y Z
GENERAL CONTRACTOR: LZ O FAX #
I am not using any subcontractors:Q
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
o$„N n � - 3 d- /
Owner/Contractor Signature Date
t
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name•, G-� Phone#:
G��i � e��FY`e-°l� y/z�-- s?�ti-fes
Contractor:��` �! Phone: License#:
!v 8GO 95�6 3 ��S73
Contact: 9 0 Phone: Q � Cupertino Business License #:
�l'u-
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: w _ �
Residential Commercial ❑
Cost of Project: qd a--7)
Strapped 11 On Platform El Bonded LJ
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
1 BPWHEATER Water Heater/Vent BUILDING
PPF.RMITFF.R Plumbing Permit Issuance_ _ PLUMBING
J BENERGY Energy
BUILDING
BUSLIC Business License BUILDING
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