04040024 ITY OF CUPERTINO ('� �'a)ya. (�'� ' -a*fiWORMAg] L��1si:
BUILDING DIVISION PERMIT Q0NTPA„up.T0 � g"�
BUILDING ADDRESS: PERMIT NO.
04040024 '
OWNER'S NAME: PERMIT ISSUE DAM
ONE: - SANITARY t&tOL NO.
ID.
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uLICENSED CONTRACTOR'S DECLARATION - lob Descriptio❑G—
1 hereby affirm that 1 em licensed anile,provision ofChapter 9(mmmencig ■ � ���m5 lion]IXIU)of DiWsion 3 of tho eusitmaa and Profession Cade.and my Ilcenso is r"nf ey d r 2JREPLACE WATER HEATER
ense Lts f�nN contractor CONTRACTOR: A & A PLUMBING APR 13- 2004
'y ARCHRECI'S otic r.aOrN
Y undcnun Ian.shall hewed
3,t Line nseJ Professional BUILDING j0 OWNER-BUILDER DECLARATION v ` �4�
Z 1 hereby affirm that I am exempt from the Contractor's License Law for the
F.a O following mason.(Section 703 1.5,Business and Professions Cole:Any city at county
u�$ which mquima a permit to construct,aimr,improve,demolish,or repair any structure
print at its utterance.also requires the applicant forsuch Permit o file a signed statement
?< N,he is licensed pursuant to the provisionaof the,Contrscuis License U.(Chapter 9 Sq.Ft.Floor Area Valua0.ol1271
z $ (commencing with Section 7030)of Division 3 of ma Business and Professions Code)ory?��
basis
olation of
S ction 7031.5 by any applicant ft flumfount and or a permit subjects r the Ne applicpant to a civilipenalty of
APN Number Occupancy Type
not mom Nan five hundred dollars($5M).
❑1.o owner of the pmpay,or my employms with wages u Noir sole compenutnn, 35916001 . 00
will do the work,and the auacthm is nmimendedoroRead fo...Ie(Sac.7W.Bumnso Required Inspections
and Pretensions Code:The Commuter Lima.Law does not apply to an Owner of q P
property w ho builds or im proves thereen,and who does such work himself or through his
own employees,provided that such improvements art not intended or offered for sale.If,
however,dte building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that k did not build or improve for purpose of
sale.).
I,as owner of the property,am eaclusively convecting with licensed contractors to
construct the project(Sec.7014,Business and proresdans Code:)The Conmemr'a Li.
cede Law does not apply to an owner of property who builds at improve,thereon,and
who convects for men pmjmm with a cmuactur(s)licensed pursuant On the Convactoes
License Law.
❑I am exempt under Sec. ,B R P C for this moon
Own. Dale
WORKERS COMPENSATION DECLARATION
I hereby aRmm under penalty of perjury one at the following declamations:
I have and will maintain a CcAfimu of Consent to sel6insum for Workr'aCompen-
uttoo,u provided for by Section 3700 of the labor Code.for Ne performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insuranm,u required by Section
3700 of the labor Cade,for the part...of the work for which this permit is Issued.
My Worker's Cnyrypreensarron Inauoerme mm. fid Polity number am:
Ca .:aSher-e —u,.a�a�/Pln a'.:OD/Z34I-2&6
CERTIFICATE OF MEMPf70t{@tOM WORKERS'
COMPENSATID RANCE
(Thu motion nod not k eumplemd if the permit Is for one hundred dollars(SIM)
or lass.)
1 certify that in the perlarmance of the work for which this Permit H issued,I shall not
employ any person in any mannerao 1110 become subject to tk Workers'Compensation
Laws of California.Dam "
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compeoation provisions of the Labor Code,you must
.JZ forthwith comply with such provision or this Permit mail k deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(" l hereby anion that there is a construction lending agency for the performance of
p3 the work for which this permit is issued(Sec.3097,Civ.C.)
a0 Umka'a Name
z, Lender's Address
U J C 1 certify that I have mad this application and sum that the above information is
IL f' correct.l agree to comply wish all city and county ordinann and sure laws totaling to
pU building construction,and hereby euNarim representatives of this city to enter upon the
r0. above-reemianed property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino again)
iA liabilities,Judgments.env and expenses which may in any way aceme against aid City
fJ nZi ihis permit.
AnPPLse A UNDERSTANDSIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ULATIONS. �_ , -Q
Re-roofs
of Applicm✓Commctur am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building Occupant store orhandte hammous material
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
oda,sedan 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yrs ❑NO
Will the applicant or future builJing.cupent vac equipment or deviceswhich If a roof is installed without first obtaining an inspection,I agree to remove
nit havakous air contaminants 11 defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
Oyes ON.
I have mad the hacardous materials requirements undcrChap ar6,95 of the Califon
nialfaltth,SafetyCadc,S.tiou 25505,25533 and 25534.1 untcuund thatifNe building
dams not current area.mna.L mut it is my msponsibility m notify the o:cuput of thc
mquimmena nth ust W mel pfl ltu sm ec (a ccnifica of Omap. /` ignature of Applicant Date
toner or amm�riaeJ agent D¢ All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
jUPEkTINO
Building Department
JOB ADORESRMIT# 0 6
OWNER'S N g RHONE # 7�
GENERAL CONTRACTOR:
Le,,-7,5,- :o FAX #
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
PlumbingAAA ILI/ g C/ 3
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/`�ap /Contractor Signature v—Date
CITY OF CUPERTINO
WATER HEATER ° o o
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
�S Y l�Df o -ate -a
Buildin Address•
vin /,/CLO K C
Owner'sName: Phone#:
q LA
� Lie
Contractor: , Phone: 4Cl� _ �3 8_$vz License#- O l 3Z3
Contact: /� n ( f , one: —7 3 g 3 9 7,9
a Cupertino Business License#:
Building Permit t Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: 2 --0-0 CIA waw ( A '
� w;'�--t.— c..neie
Residential Co rcial ❑
Cost of Pro' ct: 127
Strapped latform )ZBonded
• New Location ElReplacement
Qty .
A c ble Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING