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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CTOR+INFORMATION
BUILDING ADDRESS: _
HOTp WATER INC
PERMITN0.05050118
OWNER'S NAME:
PERMIT ISSUE DATE
L
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
Job Di t
1 hli« visions of Chapter 9 (commencing
hereby affirm thin I em nxdunderunder pro
oescrp
with S«tion ]000 of Division 3 of the Butirruand Prufeisiom Code, and my license OF
Lim.Clfor. anecrr«I. �(v /,v —:3k—
G1� - Lle. «
REPLACE WATER HEATER
_
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Date � n
Dam Con
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DEC
ARCHITECTS DECLARATION
2005
I understand my plans shall be used as public mcnrds
I Lif n
BUIL
Lkcrtsed Pmfcssionsl
OWNER -BUILDER DECLARATION
N
1 hemby affirmNal I am exempt (tent Ne Contr actor's License law for the
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following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, after. impmm. demolLvh, or repair any structure
prior In its issuance, also inquires be applicant rorsueh permit o file a signed statement
that he is licensed pursuant to due pmvisiomorthe contraemrsuecninLaw (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of NC Business and Professinm CsWe) Or
Nal be u exempt therefrom and the basis for Bin alleged exemption. Any= of
Section 7031.5 by any applicant for a permit subjects the applicant Is, a civil penalty of
]d�t�t�ear0 0
OCCU
Occupancy Type
not more than five hundred dolhrs ($500).
.3
0 1, as owner of the property, or my employees with wages as titeirsmc Compensation,
will do the work and the ameture u notimended moffered (Crash, (Sec. 7014, Bud.
and Professions count: The Contractors License Law does not apply m an owner or
Required Inspections
property who builds orimprem Flattens, and who daessuch work himselfor through his
own emphoyxs, provided that such improvements ate nmin erMW or offered for ask. It,
however, the building or improvement Is sold within one year of cmnphchon, the owner -
builder will base On burden of proving that Ite did not build Or improve for puryose of
sale.).
0 h as owner of the pmpeny, am exclusively contracting with licensed connectors to
convect thc pmject (Sec. 7064, Business and Professions Code:) The Contractor's Li
cense law does not apply an in owner of,ma eny.who builds or improves Merton. and
who contracts for such projects with a contractor(s) licensed pursuant o On Contractors
Lmme law.
0 1 am exempt under Sec. . B & P C for this wsson
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty, of perjury one of the following declarations:
I have and will maintain a Cenificat, of Consent o self -insure for Worker's Compen-
ion, ss pmvidcd for by Section 3700 of Nc labor Cade, for the performan¢ of the
work for which this permit is issued.
IC310(l
love oral will maintain Workers Cumpnwuon Insurance, as myvired by Section
of she labor Coal, for the performan«Cf On work for which this permit is issued.
y Wodwri Copensation lnwrance, canis and Policy number gertier.
�bl A� Polity No.: S y0 ✓O'
CERTIFICATE OF EKEMP ION FROM W DRKER$'
COMPENSATION INSURANCE
moSsectinn used not be completed Uthe permit is fromm hundred Nsgars ($100)
or less.)
I certify Nat in the performance of the work for which Nis permit is issued, I shall Out
employ any person hoary manner jpu an ht jec wbject m the Worked' Gompmenatlon
Laws of CalifomiF:e - 3a/O
Applicant a�-7
NOTICE TO APPLICANT: f, after making this CeniOcne of Exemption, you should
become subject to the Worker's Compensation previsions of the Ldg r Code. you mug
forthwith comply with such previsions or this permil shall be demand rtvakcd.
.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there it a construction lending agency for the performance of
the work for which Nu permit is issued (Sec. 3097, Co. C.)
Lenders Name
Leruler's Address
1 certify than 1 have mad this application and sum that the above information is
Correa I agree In comply with all city and county ordinances and sum laws mlating to
building construction, and hereby authorise representatives of Nis city to enter upon Nc
above-mentioned property for inspection
(we) agree to save, indemnify and keep harmless the City of Cupertino against
whHwnea
liebilities,judgmenB,cosuand expertscs which may in any way attruc agairus said City
in eanaquena a Jl,gylpForg arms INrtnO.
DUNDERSTSAND ND WILL COMPLY WITH ALL N-ON_-PO/INT
Issued by: Dale
SOURC OAPPLIC
Re -roofs
Signeaure of App icam/Cormage Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or bandic hazardous material
az defined by Ne Cupertino Municipal Code. Chapter 9.11, and the Health and Safmy
Cake Section 15531()? m-_�
❑ Yra
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rumor building occupant tau torment m Jcvicu hich
eqw
If a roof is installed without first obtaining an inspection, I agree to remove
it haxardnw air contaminants ss def el by On Bay Area Air Quality Management
all new materials for inspection.
svic'?
0Ya
1 have read On hvnduts malerids mgviremcrus under Chapmr6.95ofete Cahilm-
nixHealth & Safety Code, Sector. 25505.25533 and 15534. 1undermnd thin if Jin building
Joca nassmmnti have s mnam, Nat it u my responsibility to nouly the occupant of the
rtyvtrtmn wore m arn,irsvantttrnccruicateor cup y.
Signature of Applicant Date
�-J(7S
All roof coverings to be Class "B" or better
Owner or authonicd agent '-+ Dam
,
CITY Of
UPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
U
PERMIT #
6 SCS S6/(
OWNER'S NAME: Gt
PHONE #
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and comvlete the followine 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
i
Own�r/Contractor Signature
Date
•
r-,
a0F0CURTINO
CITY OF CUPERTINO
WATER HEATER b
PERMIT APPLICATION FORM
APN #
3c/a-(6 -��-7
Water Heater / Vent
Date:
s a3 n
B)din Address:
Plumbing Permit Issuance
Owner's Name-
{tir l�ww
BENERGY
Phone
vl -36
it_ vt
BUSLIC
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Contract&..Phone:
L &
License #:
7& 3 & a-
Conta t: Phone:
Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑
Plumb h/ Mech ❑
Job Description:
\
it i T F fa
Residential Commercial ❑
eEXk-r/ Or
Cost of Project: S 5D6
Strapped LJ On Platform ❑ Bonded ❑
❑
New Location Replacement
Qty- if
Applicable Fee ID
Fee Descrintinn
FPP �rlllll�
BPWHEATER
Water Heater / Vent
BUILDING
PPERMrrFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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