05120079 CITY OF CUPERTINO. "yey ��<�*f+Uyk_�
BUILDING DIVISION PERMIT � - .
Bu1LDING ADDRESS: AFFORDABLE WATER HEATERS PERMff N0.05120079
,OWNER'S NAME: PERMIT ISSUE DATE
a
EVA FUJINAGA 24707 SAN FERN O 12/14/2005
HE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EIE(,7 PLUMB MECH
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LICENSED thatIa CONnRACnder p DECLARATION Job Description
i� FF I hereby dorm that 1 am licensed under prevision of Chapter 9(commencing p
wiH Section 7001)of Division 3 of the Business and Professin C and my license is
>� mfalrnme.ndel - 73� WATER HEATER
License Clw IJc.e
C Datc Conwcmr -t
9ARCHITECTS DELLA ATION V
I undenund my
Plus shall,used u public records /»®
7 U
G� Licensed Professional
5 OWNER-exempt frDEthe ComION
I hereby affirm Nat I R exempt from the RAT( tor'!License taw for the `��/(
L O O following reason.(Section 7031.5.Business and Professions Cade:Any city or county
I3 R which re9uires a permit to emutrui eller.borrow.demolish,or repair any structure �� 4 O 0
_ prior m its lasesnm.also requires the applicant for such permit or fik a signed statement
zFF< that he is licensed pursuant to she provisions of the CommentsUeeue Law(Chapter 9 Sq.Ft. Floor Area u tion
3$ (commencing with Section 7000)of Division 3 of the Business and Profersinu Code)or
li 3
that he is emi therefrom and the bash far the alleged exemption.My vloladan of
Section 703 1.5 by any applicant for a permit subjects the applicam or a civil penalty of 3APM lqfiW&P U OCCu ype
not more than five hundred doll.,($500).
❑I.uownerofdiepmpmy,mmyemploymwlNweguudteusuleeompenudon,
will da f e work,end Nemuemrt B wt Intended or a w do
st mt apply 70as,eualrcss
and property who
ow Wild,
The Contractor's Licensendwho Law des tort apply lf rt owner of Required Inspections
Use employe build,provided
duvu H traproandwho ar easuch workhimulf or through his
awnemployes,provided N.suehimpm id wit arewtmtertdmmoRered fm Weir..
huilder the building carimprovement isoldwithinot yearw completion.the owner.
of
builder will have Ne burden of proving that k did not Wild car improve for purpose of
ole,).
❑1,u owner of the property,am"elusively conua.ing wish licensed convuorss or
construct the project(Sec.70/4,Business end Pmfeulons Code:)The Connowar's Li-
cense taw does not apply or an owner of propci Wilda or improws dame n.and
who contracts for mean pmjem with a conuctems)licensed pmrvam m she Conuscmts
Lt..Law.
❑lam"emptunder Sea ,B6.PCfmthiamssm
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I haw and will maintain aCe uricase ofcouent or self-insure for WorkeYsCompen-
73�700
an,.provided for by Section 7700 of t,labor Code,for the pertormenm of the
k for which this Permit is issued.
1 have and will maintain Wmkc's Compensation Insurance,as required by Section -
of the tabor Code,for the performance of the work for which this permit is issued.
Werke Cnam}pensadyp�.murnrtee artier sed Polley/n mbe� 53der. "//— Y✓'"y� Polity Nof: �
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(Thisuction wed not W complesed If Ne permit Isforanehundend dollans($100)
or leas.)
I certify that in the performance of tW work for which His permit is issued,I Nall net -
employ any person In any answer an as b belVme subject to He Worker{Compensation
Law,of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption,you should
,came subject to the Wei Compensation provisions of the labor Code,you most
.J 0 forthwith comply with such provisions or this Permit sball,domed revoked.
z CONSTRUCTION LENDING AGENCY
T hereby arm that Nem Is a construction lending agency for she performance of
a> the work for which this permit Is issued(Sec.3097,Cir.C.)
aO Landers Name .
o z Lenders Add.
U0 I certify that I haw read this application and este H.the above information is
IL COMM l agree to comply with all city surd county ordinances and state laws relatint se
O building construction,and hereby authodm representatives of Ni,city to enter upon she
[St AWrc-mentioned pri for inspection purposes.
G (We)agree to urc,indemnify sed kwp haredlw the City of Cupertino agalmt
y IIab1lWes.judgments,casts sed expenses which may In my way mcn,agaiast said City
U In consequence of the granting of this permit.
APPLICA U DERSfANOS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 TIONS. �/
Signs=ofApplicanUC' nrnemr g�h Dai Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant or future building=upset smm or handle havardous material
as defined by the Cupertino Municipal Cade,Chapter 9.11,and the Health and Safety
orf.semen sss31p)7
Y" All roofs shall be inspected prior to any roofing material being installed.
❑ o
Will the applicant or future Wilding occurrent sex equipmen or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haurdnus air conumiwnts u ned by she Bay Area Air Quality Management all new materials for inspection.
trict7
❑Yu u
I haw mad the h.ardous materials requirements under Chapter 6.95 of the Califor.
7dma
HUI"SafetyCedo,Sanwa 25503,35533 and 255341 understand Nat ifNe Wilding
net curet .a unuc N.It h my mapomihilky or notify the occupant of theniremutmet aarac.dn"rp'q �ySignature of Applicant Date
�cs/rpr authorized agent
/ / Data All roof coverings to be Class nBm or better
12/11/2005 08:20 66122599556 AFFORDABLE WATER HET PAGE 02/02
CITY OF CUPERTINO
WAFER HEATER U�/coo 7
CUPEI�TINO PERWT APPLICATION FORM
FD—
Building
Building Address:
p -j aCAtAaM Lo
Owner's Name: Picone#
EVa .:.' �nF �tu�-F73 . 176
License#:
Contractor: Phone: fete l
hr, b e u ca7e cs &51 7►3 1 �ca"7 3L
Contact: Phone: &61 Cupertino Business License#:
60—Ir Li1TIe. -;e- 5 -b�dD a�gso
Building Permit Info: f
Blda ❑ Elect Ey Plumb M Mech F�
Job Description: r.As
RePIGC,e. 5D ailen wolov b{eaT2r (�Ame- ISCAT12h
Residential fff Commercial ❑
Cost of Project 800
• Strapped U On Platform Bonded
New Location Re laeement
Qtyppl FeeMDescdptionFeerouA licab a Fee IDBPWHBATER Water Heate DINGPPBRMITFEB Pluznbim PBINGBENBRGY EnerDINGBUSLIC Business UING
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