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CITY OF CUPERTINO
BUILDING DlvlsloN PERMIT
CONTRACTOR INFORMATION *'
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BUR.DINGADDRESS:
L09.71 MF.NT4ART TM
NEW STRUCTURE PLUMBING INC
PERMIT NOfl5010045
OWNER'S NAME:
PERMIT LSSUE DATE
LULA MAE BAHERI
2005
ONE:
SANITARY NO. CONTROL NO.
(408)364-2143
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CON
CONTRACTOR'S DECons Chapter 9
I hereby 1 licensed
Job Description
p
affirm that (commencing
that of
am under provisions of
with lq%ry J of the Business and Professions Codc, and my liccnm is
ll fame ecDivision
met.
infullClass
c License Clan Lic. N
WATER HEATER REPLACEMENT '
:i Date Contractor
y
ARCHITECTS DECLARATION//
xm
e I unanJ my ph he shall used u public
/
3
Licensed Pnr(osianal
S OWNER -BUILDER DECLARATION
r�s0
E 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
lJ
which mquires a permit to aonswct, alter, improve, dcmnlish, or repair any .arvetum
a prior to its issuance. also requires that applicant for such pcomiuo Gla a signed statement
ithat he is licensed pursuantm the provisioe of the Comraclari Lissom Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section ]00(0) of Division J of the Business and Professions CMlc) or
_ Nm at he u exempt therefroand the hssu for the alleged exemption. Any violation of
Section?031.5 by arty applicas,to, a pevnh subjects Nc applicant to a civil penally of
3-ABI95Zih8er00
OGeo
Occupancy Type
not mom than Ove hundreddollars(SS00).
I, as owed, f,h, propeny, to my employees with wages as thci, sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec, e1]44, Business
and Predications Cox: The Conustors License Law does not apply to an owner or
Required Inspections
propeny, who builds or improves thereon, and who docs such work himself or through his
own employees, provided Nat such improvements we not intended or offered for sam. IL
however, the building or improvement is sold within one year of completion. the owner
builder will have the burden or proving that he did not build or improve for purpose of
Alie
as owner of the propeny, am exclusively contracting with licensed contractors, to
nslmct the project (Sec. 7W. Business and Professions Codc:) The Convector's U.
teem law docs not apply to an owner of propcny who builds or improves Merton. and
,
who contracts for such projects with 0 contractor(s) licensed pursuant to the Canuactor'a
Lmcr V
❑r♦unt pl under Sec. , B 6 P C for this reason
T
On)vtCcr T� `fes e
CER'S COMPENSATION DEC LA ION
1 hereby eRnm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Cement to selbinsurc for Work,', Compere
lion, as provided for by Section 3700 of IM Latter, Code, fin dm perommanee of the
'
work for which Nis permit is island.
1 hale and will maintain Worker's Compensation Insurance, as textured by Section
37M of the labor Code. for the performance ofthe work for which this permit is issued.
'
My Workers Compensation Inaunnee carrier and Policy number are:
Cartier. Policy No.: _
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(ibis socliu , lead not becompleed if are permit is reform hundred dollars ($101)
or less.)
I eevlfY Out in the performance of the work far which Nis permit 0 issued. I shall not
employany person in any Mawr in as to become subject to the Worketi Compensation
'
Lawa of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this CcniGcate of Exemption. you should
�—
become subject ro the Worker's Compensation provisions of the Labor Cox, you must
'
fanhwith comply with such Pmvisims or Nil permit shall M deemed nevolmd.
j CONSTRUCTION LENDING AGENCY
1 herebyh thi that them is construction lending agency for the Mdormanam of
' wars for which this permit is issued ISec. 30V7, Civ. CJ
s
Le
4ndch Namc
1<nderb Address;
1 I emery that I haw food Nis application and state Nn the above information is
' cones 1 agree to comply with all city and county ordinances and emm laws telling in
building eonsuumion, and hereby authorise representatives of this city to enter upon Ne
(We) agree to save, indemnify and keep hatmlees the City of Ca,v:MOD against
aconsequence o Property for iOfthis norit, s.
j liabilitica, judgencnm. corm andcxpracl which may in any way accrue against aid City
in consequence of that granting of this
permit.
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU E EG TIONS.
l
Re -roofs
rc of ApplicanUCan Lt r Dim
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant Of future building occurrent store or handle hvardous material
u defined by cite Cupertino Municipal Code, Chapter 9. 12, and the Health and Safmy
Cale, Section 2SSR(e)?
❑Yes N -
Will that appli0am or forum building Occupant use equipment or devices which
tic haraNn0 air ewuminants as defined by the Bay Arta Air Quality Management
s0ict?
❑Yea iNo
I have mad the hasani ms materials mquimments under Chapter 6.95 of On Caliror
nix H 31 h Safety Code. Sectime 25505.255)) and 25534.1 understand that if the building
docs Trot awp ndy haat atenae, thm n u ary tmpOmihility to ootily the arupant of that
requlrtmfnVwhis'h,"st iC met pro,'19nunwe of. CLNGcalc oroccupancy. _
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
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
I
CRY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER 09�r
PERMIT APPLICATION FORM
APN #
3 ��
/ S' a
BUILDING
PPERMTTFEE
Date:
Building Address:
Q�
Energy
J7/ D
Owner's Name:F
lvJ�f
sa lt'cf
PNyne o
is
Contractor
P one:
License#: 3�ay
Contact:
Phone:
Cupertino Business License #:
Building Permit Info:
Bldg ❑
Elect ❑
--- _ __ Plumb
_ Mech ❑
Job Description:
Residential
l ommercial ❑
Cost of Proj t: a�600
Strapped
n Platform ❑
Bonded ❑
New Location ❑
Replacement
CX
A&Acal�le Fee m
FPP riPC!`tY nYlnn
V-- r'
BPWHEATER
Water Heater / Vent
BUILDING
PPERMTTFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC -
Business License
BUILDING
•