05040143 CITY OF CUPERTINO w :^ 1, n + + ''"
BUILDING DIVISION PIiRMIT CCw ONIT -TOR INFORMATION,
BUILDING ADDRESS: HOT WATER INC PERMIT ND.05040143
• Orr Dill" CIART_
OWNER'S NAME: PERMITEiSUEDATE
NE: SANITARY OL NO.
ARCHITECDENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
SAS
l� p0m
c-U" )LICENSEDCONTRd modulSDECLARATION y Job Des �`�
ttt❑��� 1 Mrtby affnm IMI I em licensed under add
Piuons of Chode, 9(commencing Egr�'a'
wilM1$Cellae 70IM) of Division Jof the Business etld Professinm Code,and my licnnu is
s in full force and effect. - -
5'q= Reasof7 �Life.« REPLACE WATER HEATER /
zo Deli Cumnclnr. [
ARCHITECf$OECLA A 4 ZJUJ
'y5 < I..&.land my phos shall be good u public records
U 9
G LiccnuJ Pmfcssinnal B p I B
5 OWNER-BUILDER DECLARATION ®®V�{I IMe�,1
A 7 1 hereby
efOrm
that I em exempt from tlw Contractors License Lew for the
OO following mann.(Section 7031.5,Business and Pmfeuioas Code:Any city or county 114
$tai which requires a permit to corsgroc,,site,imprnw,demolish,or repair any Structure
FZi Prior gl its issuance,5150 reclines the applicant for such perming Rlc a signed Statement
Fxx< thathcislicensedpursuanttotMprovisionsOftheContretoriLicenseLaw(Chapter9 Sq.Ft. Floor Area Valualio
yF$ (commencing with Section 7000)Of Division J of the Blisireu end Profusinm Csxle)or
.. Net M is exempt therefrom and Me basis far Ne allcgcd caemptlnn.Any vioht(on of
Section 70)1.5 by any applicant for a permit subjects the applicant to a civil family of 3 -pBy�erO 0 Occupancy
wa mom than Ew handed delta.(M). P Y Type
0 Les owner oftM properly,or myemployees with wageske theirtalc Compensation,
will do Ne work,and the emmute is not mosided or offcreA Torah(See.7044,Bminass
and Profeuions Code:The ConlrumM1 License Law dors not apply to an Owner of Required Inspections
property who buildsor iml rows thereon.and whodoes such work himselfor through his
awn,.N.Lcu,provided theasoeh improvements are not imendW oroRerW for We If.
however,Ne building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Net he did not build or Improve for purpose of
ole.).
0 1,as owner of the propmy,am exclusively contracting with Incensed contractors to
Construct he project(Sec.7044.Business and Profeuiom Code:)The Contsacmra Lt.
come,Law docs not apply to an owner of Properly who Wilds or improws themon,and
who contracts for such projects with a contractor(a)licensed pursuant to the Contactors
License L,W.
0 1 am aempl under Sec. ,B&P C for this Mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the following declarniona
1 have and will maintain a Confiscate of Consent to se141nsure rot WorkersCompcn-
lion,as provided for by Section 37M Of Ne labor Code,for the perfo....of the
if which this permit is issued.
Mw and will maintain Worker's Compensation Insurenw,as required by Section
of the Labor Code,fa the performanec of IM work for which Nis permit is issued.
My Wmkcr�n t¢�a0�osutapw Carrier And lacy nu art
Carrier:_ ✓L OA GLI(/� Pol
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This sectioncoed not he camflewd if the permit is fortune Modred dollars(SIRp)
,it less.)
I ecnify that in she perrmmasce or the work for which MiS permit Is issued,,shell not
cm ploy any patten ip_eny me�nncfsaum Weom�A'ecuotM WOrkers'Com nsa0m
Laws of Californi! { J
Applies., /✓{ 111
NOTICE TO APPLICANT:Ir,after dolling this Ccmfaat of Exemption,Y.M..11-
become subject to M Worker's Compensation provisions of the Labor Cnda you mug
.7. z forthwith comply with each provisions or this permit shall bo deemed evoked.
z CONSTRUCTION LENDING AGENCY
F+ I herehyafRrm au thea is.cwtur.ton lendnngagmC,,for thepmfoncana or
tui 7 the work fro which this pencil Is issued(Sec.3097,Ci,C.)
W 4nda's Name
z Lendcri Andrus
U Q 1 cenify Nes 1 have read this application and safe that the shout In(OMILl00 is
U. Fcomet.1 agreei.mx
to comply with all city and county on as and stale ISM relating to
OU building Contraction,and heMbyamhorim representatives of this city to enter Orion the
ahswe-memidgm nroricny for inspection purposes.
F y (WA)ague to saw,indemnify and keep harmless tbe City of Cupertino against
inconsequent of the granting
tsind apcsuswhich mryin any way same against said City
U(� in consequence of the gaming of This fermi(.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of AppliroHAZARDOUS MATERIALS DISCLOSURE Date of Roof
Will Ne applicant of future building Occupant gore or handle haasdous mawrial
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cndc,Rc ye,25371(e)? 917/ All roofs shall be inspected prior to an roofing material bei.
❑Y=a P P Y g g installed.
Will the applicant or future building occupant on equipment or dcviea which If a roof is installed without first obtaining an inspection,I agree to remove
it haxardals it cmumaimms As defined by the Bay Area Ail Quality Management all new materials for inspection.
aria?
❑Yes u
l have mad the hnaNnus maleriahequiemcntr under Chaper695 of the Calif.,- �[ 7
iia Health&SafctyCode,Sections 25515.15533 and 35534.1 undc.arb that ifthc Wilding
es w it re
7 (r D
dotrot currently have a wren,,that it my to angry the occu cion of the
reqs _Lim CnornceNrc.wo Cup r' Signature o Applicant Date
01 agentn„= All roof coverings to be Class "B”or better
Community Development
aw-0
10300 Torre Avenue
ICupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
� �UPERTINO
Building De artment
Jos AaDE�ss: rn lo {�( v GI . PERMIT# S— d��-3
OWNER'S NAME: PHONE # - 0?�3-
GENERAL CONTRACTOR: 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
S Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing hG a( 3 ( /
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER 1� 43
CUPERTINO PERMIT APPLICATION FORM_
APN # Date:
3 5� —( "j —C7 2S
Buildin A)10(49 G�
Owners e: Phone#
ell c A4-e� — 53 4
Contractor: Phone: License#:
HOT WATER, INC. (p 5D (OSI 8K9 7(p 3(pl a-
9631N U
Contact: N CARLOS. CALIFORNIA 9401thone: Cupertino Business icense#:
02,
Building Permit Info: /
Bldg - ElElect El .. -Plumb .D- Mech ❑
Job Description:
ct,ce. ae v ler, ism(c, /1. 5e rdvls Tt-P
Residential Commercial ❑ '" fa EAflev(cc
Cost of Project: -
.......: . .
Strapped ❑ On Platform ❑ B fled- ❑'
New Location ❑ Replacement
- -Qty. if -
A" licable Fee ID Fee Descri tion Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING