04030024 CITY OF CUPERTINO
BUILDING DIVISION PERMIT $ C0NT'�0TRI�`'6RIM�' Y �e"` -
u
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT N0.04030024
OWNER'S NAME: PERMIT ISSUE DATE
SHI
NE: SANITARY NO. 2 0 OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
e BO EO PLU=MB MO
+100 LICENSED CONTRACfOR'SDECLARATION JobDescri tion
0 1 hereby af=ro that l am licensed under provishma of Chapter 9(commencing - p
N with Section 70110)af Division 3m`the Bmwaw and Pmfcsskma Code,and my license is
! in full foredNn ffen 9
q 'fall C c x m 1y $ 0 REPALCE WATER HEATER F,NAL �' tD
A CHITECI'S DECLARATION 4 ZOOM
1 understand my plain shell he used u public records
3 0� Licensed Professional
MAR 2
305OWNER-BUILDER DECLARATION
I bean affirm that 1 am exempt from the Cmrrnclar's License Lew for the BUILDING t
too following mason.(Suwon 7(B 1.5,Business and Professions Code:Any city or county
i<$ which requires•Permit to construct.altar,hnprove,demolish,or repair any structure
',a^Z j- pd.,to its issuance.also requirosme applicant forsuch permit to rile A signedstatarrom
$$xx< that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuatio
gF0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of rA�owi�A1s�wr1.
Swmm 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 m1f adv V IYU.wPsrO 0 Occupancy Type
nut more Nan firs hundred dollars(5500),
❑I,as owner of the property,or my employee with wages as their sole compensation,
will do the work and the mucmm is not intended or offend forsale(Sec.7014.Business
and Profeseians Code:The Coauaclnr's License Lew does not apply In an owner of Required Inspections
property who builds or improves themun,and who does such work himself or through his
own employees,provided thalsuch improvements arc notimmnded or offered for sale.IL
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build m improve for purposa of
sale3.
❑I.as owner of the pmpeny,am nxclusively contracting with lim cad connumrs to
construct the project(Sec.7040,Business and Professions Code:)The Connector's U.
cams,law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a comnclor(a)limned pursuant m the Communes
License Law.
❑1 am exempt under See B&P C for mu recon
wner Dae
WORKER'S COMPENSATION DECLARATION
I hereby Affirm under Penalty of perjury one of the following declarations,
�J 1 hem and will maintain a Cenificate of Consent to self-insum for Workeb
Compen-
satl.n,,u provided for by Section 37M of tiro labor Code,for the penfornence of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurmm,as required by Section
3700 of the Labor Code,for the performance of the work fmwhich this permit is issued.
My We,it LFP!.radon Insunnm rticr end Policy number am:
Carl cJ .r�4/G �ssuAl Policy No. 371�'OD
CERTIFICATE OF EXEMPI70N FROM WPRKER '
COMPENSATION INSURANCE y'1(
(This=[I..need not m completed If the Fermi,Inform.hundred dollen($lm)
or Ices.)
I certify,that in the performance of On work for which this Permit is issued.I shell not
employ any person In any manner an ai to become subject to the WnfkerSL'ampensadna
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CcniOcale of Exemption.you shouW
become&objet,to the Worker'3 Compensation provisions of the labor Code,you must
.,0 forthwith comply with such previsions or this Permit shall M deemed revoked.
'z y CONSTRUCTION LENDING AGENCY
[—r Ihereby affirm Nal them is a construction lending agency for me performance of
Ci w�i the work for which this permit is issued(Sec.3W7,Civ.C.)
Q Lendusi Name,
z Lender's Address
U O 1 ccnify mat I have read this application And atom that the above infoonetion is
IT.rcoma 1 agree to comply with all city and county ordinances and suits laws relating in
O V building construction,and hereby amborim representatives of mis city m enter upon the
Da above-mentioned property,for inspection purposes
a (WC)agree 0 saw,indemnify and keep harmless the City of Calandra against _
h liabilities,judgments.coats and expenses which may in any way accrue against said City
(„)',Z in coneguenm of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILCOMPLY WITH A L N -POINT Issued by: Date
SOU E EGU TION _
e o o Re-roofs
gnamrc of AppliaHA2AR OUS MATERIALS DISCLOSUR Dam Type of Roof
Will me applicant orfulum bulldin6omupentstorc or handle haaardous mamdel
as defined by the Cupeninr Municipal Code.Chapter 9.12,and the Health and Safely
ads,Section 25532(x)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant or future building amupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hamknus air conmminanm as rinsed by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea Nu
1 have mad On haramousmxerials mquircmcnts under Chapmr 6.95 of the Califon
ria Health&Safmy Cad.,Swoons25505,25533 and25534.I um1crswnd theif the building
does nut currently have a mean,Our it is my responsibility to nem'y the oecupant of the
regal enuwni. mamis mis c faccmB.ate r al a SignatureofApplicant Date
wn.rorauthrrimdagent Day I All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CI OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESSgc:�O, PERMIT#
/a !ice 37
OWNER'S N 1pct Z A PHONE #S/o L.66'/- 7 D9 i
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin 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 Lc
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO b 03Wd 2
WATER HEATER
CUPEfkTINO PERMIT APPLICATION FORM
APN # Date:
D71-
Building Address:
Owner's Name: Phone#:
Contractor: Phon . !d Li nse#:
c
Contact Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential mm rcial ❑
Cost of Project: d µp
• Strapped n Platfo Bonded ❑
New Location ❑
Replacement
Qt . if,
A lic 1 Fee ID Fee Description Fee Grou
BPWHEATER Water Her/Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING