03090184( ' CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTn-RTNFORMATiON.
9u1 LDING ADDRESS: WATER HEATERS ONLY PERMIT NO03090184
122 MTT,KY WY
a OWNER'S NAME: 970 E. MAIN ST, SUITE 200 PERMIT ISSUE DATE
JAMESHEN 2003
NE' (800) 835-5946 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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±oo LICENSED CONTotal.. I DECLARATION Job Description
I U w 1 Sknob,ection 700D)
D)of that 1 am Iimved under praviaiorts of Chapter 9(commencing p
iN Scclion]IXNn of Division 3o da Basin i orb Profcssium and myli seis
a in fullfotccandcffaTt. EPLACE WATER HEATER
=
LIC ` L' /O
Gain
F ARCHITE S DECLARATION /
IwU
IundcrstanJ my plans shall heusedazPublic occurs. 0/
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SQA Liccnaod Professional `\.J!
5 OWNER-BUILDER DECLARATION
X 1 hereby affirm that I am exempt from Ne COmOelars License Law for the
OO following mason.(Section 7031.5,Business and Professions Code:Any city or county
S$V which requires a permit to construct.eller,improve,demolish,or MCFQM any suucturc $700
_Zy prior to its issuance,also requires the applicant forsuch permit to File a signed statement
;EEO that heialcensedpursuant tothe provisions nfthe Contnctor'sLicense Law(Chapter 9 Sq. Fl. Floor Area Valuation
2f- (commencing with Section 7")of Division 3 of be Business and Professions Code)or
that he is e¢mpt therefrom and Use baeu for the alleged exemption.Any violation of 36220002 . 00
Section 7031.5 by any applicant for a Permit subjects she applicant tm a civil penalty of .APtSt Number . . _ Occupancy Type
not more than five hundred dollars S500). '" - - - P Y - -----
I,an owner of the property,or my employees with wages as their axle compensation,
will do the work.and the structure is not intended or offered far aale(See.7W.Business b02 —
and Proroks am Code:The Convector's License Law does not apply to an owner of 506 - GAS T c
P who builds 0r impmws Norton,and who does such work himself or through his
own employees,provided that such impmvemenu am not Intended or offered for sale.If. 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion.the owner-
builder will base the burden of proving Nat M did not build or improve for purpose of
salt.).
❑ 1.as owner of the property,am exclusively contracting with licensed contractors to -
construct the project(Sec.7044.Business and Professions Cole:)The Contractor's Li.
erns,law docs not apply to an owner of prop,ny who builds or improves thereon,and
who contracts for such projects with a contractots)licensed pursuant to the Costncmts
License Law,
❑I am exempt under Sec. ,B&P C for this reason
Owner Date
"- WORKER'S COMPENSATION DECLARATION
Ihercbyaffirm under penalty of perjury one of the following declvatimur
1 haw and will mainuin a Ccnif oto of Consent to self-insure for Worker's Cumpcn.
tion,as provided for by Section 3700 of the labor Coda for Ne performanen of that
work for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Sectio
700 arctic labor Cade,for the performance or she work for which this permit is issued.
My Work Comps hon Insurance carrier and Policy number am:Camcr. a� Policy No.:�Jy +tom
CER IFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(olssection need not M completed Rik Permit is throve hundred dollen(SIM)
loss.)
1 certify Net in the performance of the work for which this Permit is issued,I shall nut
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Cali(ornia.Dare
Applicant
NOTICE TO APPLICANT:IL allot making this Ceniricate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
�O ROOM th comply with such provisions or this permit shall M deemed revoked.
Z y
CONSTRUCTION LENDING AGENCY
1 hemby affirm Nat there is a convection lending agency for be perrurmance of
Y. thc work for which this permit is issued(Sec.3097,Civ.C.)
1 Q L,nder)Name
3 z lender's Address
J 0 I ecnify that I Mese read this application and sate that the above information is
y F correct.I agree to comply with all city and county ordinances and state laws relating to
Z)U building construction,and hereby authorim mpreseckdomc of this City to enter upon the
J+a ahove-mentioned progeny for inspection purpoxs
(We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgmema,costs and expenses which may in any way&come against said City
J in conseyuc f the
granting a is pormrh'
APPLIC UNDER A NO WI COMELY WITH NON-POINT Issued by: Date
5 UR eU N� / �7 Re-roofs
Signature of Applica i/Contracmr Dole
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building uccupantstore or handle ha mous material
as defined by the Cup,nam Municipal Code.Chapter 9.12,and the Health and Safety
,jiEcdc.SCCIl Ca 25572(x)? All roofs shall be inspected prior to an roofing material being❑Yea g�- P P Y g g installed.
Will the applicant or future building Occupant use equipment ordcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
it homrdnus air contaminants as defined by ILC Bay Area Air Quality Management all new materials for Inspection.
strict?
❑Yes y 9"
1 have mad thc hmaNaus materials requirements under Chapter 6.95 of thc Califor-
nor Health&SafctyCadc,Sccdom 25505.25533 snd 25534.1 undersand Nes if tM building
docs not cameralmoan at' y respo inc,mpory,thccu
c occupant of be I,
mquiremena mus. It seaamee ce a .(OVV0 -Signature of Applicant Date
Owner or authorized agent 7f Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER 03
CUPEII;TINO PERMIT APPLICATION FORM
APN # 36 -2- ,1,0 9 4->.Z' Date:
�-3 GJ
Building Address:
Owner's Name: Phone #:
Cont ct r: Phone; License #:
27',-3odl .3 7 SY573
Contact Phone: Cupertino Business License#:
Building Permit Info
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential ommercial ❑
Cost of P ject:
X00
Strappe On orm Bonded ❑
New Location Cl Replacement ❑
Qty. if
ApOctVie Fee ID Fee Description Fee Group
BPWHEATER Water.Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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