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CITY OF CUPERTINO
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5 INFORM T
BUILDING DIVISION PERMIT
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au1LDINGADDRESS:
SOUTH BAY PLUMBING
PERMIT NO 05120035
865 MC CLELLAN RD
R'S NAME:
PERMIT ISSUE DATE
CIDY PARSAY
441 N CENTRAL AVE
12/08/2005
E;
SANITARY NO. CONTROL NO.
(408)370-3535
ARCHITECr/ENGINEM:
BUILDING PERMIT INFO
9LDOO
jsfPLUMB
O 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Net 1 am licensed under pmviaions of Chapter 9 (commercial
with Section 7000) ol'Divolon 3 of the BuaineY and Pmfeam na Code, and my license is
infull fonre endeffec / 6' (
REPLACE WATER HEATER
Licence — G C. N
CamDECL O Ir
w "��
Dam
ARCHI,shsllECPS OEC RATION
I I understand my plain shell be wed As public rtMNs
la/0®
Limmod Professional
OWNER -BUILDER
"
mDECLARATION
1 hereby .(firm that 11. exempts License Lew for the
the Cssions
o
an Code: Any city
followingmrsoa Permian 71omme Business and Mu.ry
dcrimlt
st
improve, ri mash my taamure
which rtqulma a permit re Blur, improve, do
wires oct
Permit I
! pdoreits lYuane0.aeu requires tedvisionof f Contractor'ste a
is NCue
Sq. Et. Floor Area
Valuat
(what be, pursuant to the provision rel
commencing with of nrw Busiurc4rod Prscltw(Chapur9
iN Satiown
Al egad exempt on. My
Net Ise u exempt utere(rom and Ne bub for dm alleged exemption. My violation of
Met he is exam and basis
AION MittiVer
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applicant m a civil penalty of
tint mine Nen 0w hundmd dollen (5500).
❑ L u.wner a(dm property, er my employcea with wAgea Y deb Bole eompewdon,
Required Inspections
will do the work, and dreawmure is mu mended or offered foratle(Sec. Trial, Business
and Profession. Cade: The Commalm'a Lim me Law does not apply m An owner of
q p
propeny who bui Ids m Improves Unman, end who does much wink himself or through his
own employes, provided that such Improwmenu ere ant Intended arolferW fmaae. if.
however, Ne building or improvement is told within one your of compedan. the owner.
builder will have the burden of proving that be did Out Wild or Improve for purpose of
sae.).
❑ 1, a owner of the property, am exclusively mn=ing with licensed cammemon to
convect the project (Sec. 7(344, Business and Professions Code:) Tom Contraemh U.
cense law does not apply m an owner of pmpeny.who builds or Improves theme, and,
who contncu for such projects with a conuxer(s) licenced pursuant to the Contractors
License Law.
mexemptumier Sec. ,B&PCforthismeson
Dell
WORKERS COMPENSATION DECLARATION
1 hereby eTBren under penalty of perjury one of the following declarsti.ns:
aw end w111 mainui. •Ce dri.m of Consent m ul(-Imam Ise Work e,Campcn-
, u provided for by Section 3700 of the Labor Cade, for the performanee of the
13701afthe
for which this permit Is issued.
Iand will maintain Workces Compensation Ietuuue, u required by Section
Labor Code, far Ne performance of Ne wort far which Nu permit Is issued.
orker's Compensation Insurance carrier end Policy nnummber are:r.
SV Mt' �y,Cj c. 4'�`^/ Polity No.: LddSj� ���t
ty(r0(
CERTIFICATE�CEMPTION FROM WORKERS
COMPENSATION INSURANCE
mals section need noted completed if Ne permit Isforme hundreddollan (SIM)
M, leu)
1 certify Not in the romforma.. of the work for which this permit Ie issued, l Nell out
employany person In my mNmf an Y in become subject to the Worteli Comperlaadon
laws of Califomia, Doe
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worke's Compermom provisions of m. labor Cod., you meet
forthwith comply with such provisions or this permit shall be doomed rooked.
CONSTRUCTION LENDING AGENCY
rdemm Ish . s lending agency for N. perfurmmce of
I hereby alarm der
ed (Sm
weft for which Na permit ts issued (Sec. 7091, Civ. C.)
Le
Lander', Name
,
lender's Address
I certify that I haw need Ws application And mm that dm aWve information Is
'
mortem. I agree to comply with all city and county ordinances and sate lave relating to
building eomwcti.n. and hereby aummire representatives of this city to enter upon the
above-mentioned property for impaction purports
(We) agree to an. indemnify And keep harmless Be City of Cupertino against
Iiabllides, judgments, costs And expenses which may in My way AC.roe Against said City
In cone pumm of the granting u( this It.
APPLICANT UDWRSTANDS ILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RONS. j
Re -roofs
Type of Roof
JJ s� f2—! O5
SrM of Applr =US—MATERIALS rtDAe
DISCLOSURE
Will the applicant m fuwm Wilding or handle h material
Health a
speed by dm Cupertino Municipal Cade. Chepmr 9,13, and the HceIN and Sanity
k, Chapter %1
. Sectio. 25533(47
❑res EPA
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or fuwm building Occupant ter equipment or devices which
t heYNous air conuminanu As defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes rIU�"�
�
I hew read the haYNmumeerials requirements undcrCMpmr A95 ofde Califor-
-
m.H5suryCa4.Secvoru3SS0 33am125534.IaMcrsuM thmif Ne building
dCY�O.lnC Ant, N laymapamlMhlyy0.up....NO
hien ubumet oro' aance.faCcrarcam Pony.
/ L -k
Signature of Applicant -Date
All roof coverings to be Class "B" or better
00-_11-511h
n_zcd4Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:c C ��
2/ 6 5 r1 I l i.
PERMIT #
/ J
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
tune Date
Please check annlicable subcontractors and comvlete the following information
/Contractor Signature
I2 -S -- S
Date
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
'T�
/Contractor Signature
I2 -S -- S
Date
r
J
CITY F
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER3S—
PERMIT APPLICATION FORM
APN #
357
N 007
Date:
/z
Building Address:
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
Owner's Name:
BUSLIC
Phone k
BUILDING
cPat r 5 a
Contractor:
Phone:
License #:�
YS So
Contact:
Phone:
Cupertino Business License #:
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g 3S S S.D
Building Peimit Info:
Bldg ❑
Elect ❑ Plumb 0�
Mech ❑
Job Description:
(-
Residential Ea7 —
Commercial ❑
Cost of Project:
Strapped
On Platform Bonded
New Location ❑
Replacement
Qty. if
A __1:....L1., Tz-- m
Fae ileccrintinn
Fee Groun
BPWHEATER
Water Heater / Vent
BUILDING
/ PPERMTTFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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