04070146 CITY OF COPERTINO '"g}� - c•, .
BUILDING DIVISION PERMIT ��+'7"rr• v ^"^ """'�
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BUILDING ADDRESS: TOM' S PLUMBING PERMITNO04070146 '
2734 MAJESTIC OAK Wy OWNER'S NAME: PERMIT ISSUE DATE
MAVIS SMITH 12 /24
ONE: SANITARY NO. CONTROL NO.
(408) 867-6010
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
roc LICENSED CONTRACTOR'S DECLARATION - Job Description
C 1 hereby affirm That 1 am licensed under proviaions of Chapter 9(commencing
b wish Section 7001)of Division 3ofOa Beat..and Pmrcaslons Code,and my Kanto is
D! inrmlmreande kI I REPLACE WATER HEATER
ng? Licence Clew
p Data Ca hero,
{q-uU❑tl ARCHITECTS DEC 1 N
?a 1 undcrelend my plana shell bouwd es pub c rccnrds AUG 2'� 2004
SCS Licensed Pm@sa...I
g OWNER-BUILDER DECLARATION �Ue
1 hereby affirm that I am exempt from Ne Ci m mcmr's License Lew for the ���as.
0 following re=on.(Section IID L5,Business and Pmfessinna Code:Any city or county
B0 wM1ich myuims a pclmil w construct,alter,improve,demolish,or repair any structure
prior him issuance,also aquimstheapplicant fo...ch permit to Ble a signedslotemenl
< that he is licensed pursuant the provisions of the Commcwr's Licence Law Sq.Ft.Floor Area Valuation
tt
SFO (commencing with Sound.7000)of Division 3 of the Bie inexsend Portentous Code)or
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that he Is exempt thmcfrom and the barb for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a Permit subjects the applicant to a civil penalty of 3 48XN24ll 0 Occupancy Type
not more than five hundred dollars($500). -
0 I,as owner of the property.of my employee with wages=their sole compensation,
willdo the work and thesvumure isnot intended moffered Forseb(So.7044,Business Required Inspections
and Professions Code:The Contractore's License Law docs not apply he an owner of q p
property wha bui Ids or improver thereon,and who does such work himself or though his
awn employees,provided that such improvements arc not intended or offered for=te,if,
however.the building or improvement is sold within one year of completion,the owner
builder will batt the human of proving that he did not build or improve for pugmse of
salad,
0 1.as owner of the property,am=elusively conducting with licensed convectors un
construct the project(Sec.7044,Business and Prof elions Code:)The Contractor's Li-
caws law does not apply at an owner of property who builds or improves Neeson,and,
who contracts for such prejects with a conusewr(s)licensed pursuant to But Contra use's
License Law.
0 1 am exempt under Sec. B&P C for this rearon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury mu of the fallowing declarations: -
1 have and will mahouts a Cemficaw of Consent to self-Insure for WorkeYe Contain.
=tion.an provided for by Section 37W of the labor Code,for Ne performance of the
W
ork for which this permit is issued.
EQ 1 have and will maintain Worker's Compression Insurance,=required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Workepr's�Compensation Insurance canner and Policy number am:
Cartier. fMY/PV`W]
Policy No.: 20i'1 '
CERTIFI ATEOFEXEMPRONFROMWORKER '
COMPENSATION INSURANCE
(This adiom need not be completed iHhe Permit is Corona hundre id disco($100)
or less,)
1 certify that in Ne Performance or the work for which this permit is iasued,l shell nut
employ any person in any manner so an In become subject to the Workers'Compensation
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
Income subject to the Worked Compensation proviaions of the Labor Code,you must
,JQ for0with comply with Such provisions or this permiuhut[he dccmcd revoked.
'Z CONSTRUCTION LENDING AGENCY
[., Ihereby affirm Nat there is a construction lending agency for the performance of
y a7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Nam.
G Lender's Addreas
U O I cantly that I have read Ibis application and sum Nat the shove information is
Ua F correct.l agree to comply with all city and county ordinances and slow laws misting w
0U building construction,and hereby auflumner mms
penwes the of city w enter upon the
U .hove-mentioned property for inspection purposes
0. (We)agree to save,indemnify and kap harmless the City of Cupertino against
In liabilities,judgments,casts and expenses which may in any way seems against said City
U Z in consequence of the granting of this permit.
v..i APPLICANT UNDERSTANDS AND WILL PMKY WITH ALL NON-POINT Issued by: It rate
SOURCE REGUL#10..S.
C !)-Z?'0'7 Re-roofs
Sign t a ofAiPliumoVondomed, Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dw applicant ar future building occupant atom arhandlc hanamous material
an defined by the Cupenino Municipal Cade,Chapter 9.11,and the Health and Safety
Cods.Bathes 25532(a)1 -
-7 Yes All roofs shall be inspected prior to any roofing material being installed.
�RJo
Will the applicant at future building occupant use equipment at devican which If a roof is installed without first obtaining an inspection,I agree to remove
mil lumardous air contaminants=defined by,the Bay Area Air Quality Management all new materials for inspection.
7does
istrict?
❑Yes (f Nu
1 have read the hi smnusmatenals requirementsunder Chapmr 6.95 ofthe Califor.
ia Health&SamayCode,Such ons15505,M33 and 15534.I understand that if the build' 7
not currently have a tenant that it is my responsibility w notify thm occupant
yuir mcnlo which muu be met prior ssu cola Ccnificam of Occupancy. $I azure of Applica Date
own r author .ad agenll 7^Date All roof coverings to be eTass"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS^ a �� p �� PERMII
OWNER'S NAME: MR i s Sw 7G PHONE # z - -75-kr
GENERAL CONTRACTOR: FAX # o
I am not using any subcontractors:
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
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing D N
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/Contractor Signature Date
r
CITY OF CUPERTINO
WATER HEATER o l
CUPEkTINO PERMIT APPLICATION FORM
APN# Z
Date:
Building Address: 0 J
�I /c
Owner's Name: Phone#:
AV SSYV '-( A, A-S -
Corr Phone: License#:
Iow" S PL,/wALi - 60 0 8 /
Contact: Phone: Cupertino Business License#:
7
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ® Mech ❑
Job Description:
I& 4 Ace 4e z
Residential Commercial ❑
Cost of Project:
Strapped On latform Bonded rl
New Location ❑ Replacement
d if
a Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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