04020054 CITY OF CUPERTINO 11 V1 � fT I
.g
BUILDING DIVISION PERMIT N ,GTORJVO
BUILDING ADDRESS: WATER HEATERS ONLY PERMITNO04020054
InjAg mArAnAD4
OWNER'S NAME: PERMIT ISSUE DAM
�L__ALT;F.RT MAK 970 E. MAIN 2T-1 PAQ Q;;I.()r 12
4E: SANITARY O. �gkl,NO.
(Rno) 8-�s-c;qctr
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGMECH
ee
LICENSED CONTRACTOR'S DECLARATION I = its PLUMB
M I hereby.111.that I.m licensed andia,,novi,mus of Chips.,9(commencing Job De ' '
with Section 7").fDlAskoo 3 of Business ted PrOficuroom Cods.md my license is
;N _7 5,7_P , REPLACE WATER HEATER
M in full force and clffct�
Licm.Ciw -
am AgAMAR - 5 2004
Ole I andaratand my plans.711 to used as public mc5rd,
Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
I hereby affirm that I am exempt from the Contractor's License Law for the
0 D following mason.(Section 7031.5,Business and Professions Code:Any city or county
n which.,.I.a Permit to exisistra.u.alum,am,.,demolish.mr eput,any mruchamc
!:4< Prior to its issuance.also requires the applicant for such permit to File a signed statement GG
Net he is licensed pursuant to th,previsions of she Common's Licents,Law(Chapter 9 Sq.Ft.Floor Area Valuatioig
(commencing with Section 7")of Division 3 offlic Bunifinamard Proficusion,Cade)or
Nat he is,
exempt Uncraform,and We basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects line applicant in a civil penalty of
not mom dean five hundred dollars($500). MMM"(;ro 0 Occupancy'lype
0 l,mowner oftWpmpcny.mmyemployes with wage mffieiranlecomNnution,
willdolhowork.annifteximlu.N.ti.Mndcdooffemdforsale(Scc.7044,Bu�ms
and Prallostong Code:To Zrimetor's License Law dors not apply in an owner of Required Inspections
property who WILL,orfinsproves,thereen,and whodatessuchwark himsciforthrough his
Own employees,provided tbatsuch improvements are intended oroffined!forsade.If.
however.the Wilding or improvement is old within one year of,sempledon.the osvnaxr-
builder will have Hie themign of proving gia,he did not Wild or Impose for purpose of
sale.).
0 1,49 Owner of the Property,am exclusively contracting with licensed contractors,to
construct the pmjcct(Sec.7044.Business and Professions Code:)no Cantractor's U.
em"Law does out apply to an Owner of property who builds or Importer thamon,and.
who contracts for such projects with a contracurms)licensed pursuant to the Committees
License Low.
r]larnexempt under Sec. _.B&PCfar Nis remora
Owner Data
"' -
WORKERS COMPENSATION DECLARATION
I hereby anion under penalty of Perjury one of the following declaration:
I have
and vvflI maintain.Cim]fmadd Of Consent in self-Insure for Worlems Compo.
I
md.,as pmidcd for by Section 37W of the Labor Code,fix the performance of the
work for which this Permit is Issued.
work
I have and will maintain Worker's Compensation Insurance,as required by Section
I
1D of the Labor Code,for thc perforemem,of the work for which this permit is stated.
'Y'
MYWmlm' C it it Policy monism am:
Cartier.Co3 OmPs PoIkNo.;W?Sq2_-3
Carm - Zur'"c'""""an
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mos amount need not Isecompleted Ellic parmitis forces hundred dollaro($10(71)
or less.)
I"miry that in the performance of she work for which this Permit is issued,I shall nut
employ any person in any manner an as in become subject in tie Wormer Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT'.If,after making this Ccifilicam of Exemption,you should
become subject to the Worker's Conservation provisions of the Labor Cook.you mot
Z romb,sks comply with such provisions or this Permit shelf W deemed resulted.
Z 0
CONSTRUCTION LENDING AGENCY
1 harchy,affirm that there u.mmatruethim lending a,me,for the performance of
> the work for which this permit is issued(Sm.3097.Civ.C.)
Lender's Name
Lender's Address
I codify that I have need this application and shim that the above information is
IL. came%.14,om to comply with all city and county ordinances and soon]am misting in
QU building construction.and hereby audersire rapreacroadivio;of this city to enter upon the
above-manneredproperty for inspection poPeons.
gL (We)agree to sere.indemnify and keep hourclars Has City of Cupertino against
lialailitics,judgments,costs and expenses which may in any my scenic against mid City
inconsequence enc
of the granting of this mit.
C PLY WITH ALL NON-POINT Issued by Date
SOURCE R LATI
APPLICANT ERSTA S
Re-roofs _C7
Signature of AMlicant/Contruchur Doo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant store or handle hazardous material
Imtdelnd I.y.dW,Cu(p,1;mmc Municipal Code,Chapter 9.12,and the Health and Safety
de.Section
?
Mye, All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hay.ardous air contaminants as defined by the Bay Am Air Quality Management all new materials for inspection.
7Dishict?
0 yes
I have mail the harmindous materials requirarecour unniarCh.,tim6.956the Califit,
nicHmith&Safety Code,Sectiess M505,25533 oil M534.I accounted ftifthe building
does
Out cumcnilyA.a moem, I ymspons lityWrioifty the occuparnofthe
rNui
�u monents wwrolus"'t to. U.cc.r erfificat.f0maparmy. Signature of Applicant Date
W�l �0�
�,mmth.rixcdagerl Dam All roof coverings to be Class "B" or better
4-4
CITY OF CUPERTINO u
WATER HEATER
CUPEI�TINO PERMIT APPLICATION FORM
APN#� /Cj a/ 6� Date:
Building Addres$: /
Owner's Name: Phone#:
Z;$3 - 2—F Z$ .
Contractor: }, j License#: 3 -7VS 73
Contact: �'/ Phone#:
ApplicanU6eff4aetor:
Building Permit Info:
Bldg Elect lumb Mech
Job Descri tion:
esidential- �/� ? Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: 12
9�p
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License
BUILIDNG
2