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CITY OF CUPERTINO"
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CONTRACTOR INFORMATIONfi
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
WATER HEATERS ONLY
PERMIT No 05060004
OWNER'S NAME:
T)AN (SENTRY
q7f) E MAIN ST, SUITE @99--
PERMIT ISSUE DATE
ONE:
SANITARY P,6. �ftOL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRADECLARATION
Job Description
1 affirm Nat 1 am cantle, of 9 (commencing
under Pd
P
darns
f ft Bu s c.de'
with Section 7IXX) of Division 3of NCBminca and rufcssine Codc, an ry liccnso is
ion 7
in lull force and e `5 el _ a
Licensoe.
LACE WATER HEATER?p,^I �j
Dam G
ARCHITECTSDECLARATION
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I understand my Phe shtll W ecd n public records
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Licensed Plufcssicnal
OWNER -BUILDER DECLARATION
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I home, affirm Nm 1 am exempt room Ne Card ractar's License Law for the
followingrcman. (Section 7031.5, Business and Professions Code: Any city Or county
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which requires a Permit to construct, slier, improve. demolish. m repair any structure
1111 Phil
prior to its issuance, also require the applicant for such permit to file a signed statement
Out he is licensed pursuant to the previsions of Ne Comsseum's License Law (charter 9
Businessland Pioe Cecil or
(commencing with Section 7")of Division 3 of0m rofen
290
Sq. Ft. Floor Area K"t�/a/fh( Valuat on
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that he u e¢mpl Ne¢fmm and the basis for die alleged exemption. Any violation of
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Section 7831.5 by any applicant for a permit subjects the applicant w a civil penalty of
3 TFNi 24grO O
---Occupancy Type
not mom Nan five hundred dollars (5500).
❑ I, as owner ofthe property, or my employees with wages u their sole compensation,
will do the work, and the stratum, is marracnded moffemd rorsale (Sec. 7044. Business
and Plutonium Cade: The Comes:mrs Liana Law does Out apply to an Owner of
Required Inspections
property who builds orimpraas daemon, and who dassuch wmkhimself or through his
own employees, provided Not such improvements sro ornamented worked for tile. If.
however. Ne building err imprevcmcat is sold within one year of completion, the a.,.
Witter will have IW harden of proving Nat he did ren Wild or improve for mcpsam of
sal.).
El 1, as Owner of the property, am exclusively contracting with licensed convectors to
construct the project (Sec. 7W, Business and Professions Code:) The Contractor's Li.
cane Law does not apply m an owner of property who Wilds or improves daemon, and
who canta cu for such projects with a eontrutor(s) licensed pursuam to the Convutor's
License Law.
1 am exempt under Sec. , B & P C for Nis reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pcnahy of perjury One of the following cladmatioe:
I ham and will maintain a Certificate of Continua self -insure for Worker'sCompon-
act n, as; provided for by Section 37W of On Labor Code. for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, n myuired by Section
W of an, labor Colo. for the performance of dm work for which this permit is issued.
My Worket{y�Comp�emffion Whom nce airier, and Policy number arc:
Cartier. iry No.:
_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mcbsuetion reed not be cmadcled if the permit is for unchurched dollars (51 W)
or loss.)
I certify thm in the parr aOmea of Oc work for which this permit as issued, I shall nut
employ any person in any manner so as to become subject o the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making Nis Ccrdficate of Exemption, you should
beenme subject m the Worker's Compensation previsions of the labor cone, you mut
foMwoh comply with such provisions or this Permit shall W deemed revoked.
.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a construction lending agency far the performance of
,be walk fur which this permit is issued (Sec. 3087, Civ. C.)
lender's Name
'
-
Lender's Address
1 certify Nat I have lead ons application and sum Nat the eWve information is
-
contact. I agree w comply with all city and county ordinances and sum laws misting w
building construction, and hereby Ruthann reprascnutivcs of this city m enter upon dw
aMve-mentio fan impaction pugroxs
(We) agree to save, indemnify and kap harmless the City Cupertino
of against
mentac st
liabilitics,judgments,cosn and expenses which may in any way accrue against said City
ancomaA m fNO oe
Rrano Cor D WIL OMPUr' WITH ALL ON-POIW
Sig s.
Issued by: Date
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Re -roofs
Srgnuum of Applican✓Conuacmr Dau
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant ser future building aceupantswm or handle Invocations material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cotte. Section 25532(a)7
❑ye mom-
All roofs shall be inspected prior to an roofing material beim
P P� Y g g installed.
Will Nc applicant or (umm building ottupam sou equipment or device which
If a roof is installed without first obtainingan inspection, I agree to remove
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II havardoua air contaminants n formed by Ne Bay Aura Ail Quality Management
all new materials for inspection.
iWlel?
❑Yes
1 have matl IW avardnusmaerialsrcquircmcnu unto Chapwrh.95 ofthe Glifoo-
ria Hca]O& Safcty Cade. Sections 25505, 25533 and 25534.1 understand thatifNc Wilding
docs not currently have a mnanl Nat it is my responsibility w natty dw mcupand ofam
myNmmentswhich IOurwi comet ora cerdecaw O(a�a
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Signature of Applicant Date
a e
All roof coverings to be Class "Br' or better
Owner OraamariZOd Went Daw
CITY OF
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
/0g9�Q 1�- a�w �d
PERMIT #
o6Doo
OWNER'S NAME: ' G
PHONE #
GENERAL CONTRACTOR
FAX #
I am not using any subcontractors: l3 a$„ i4J� zY d 5
Signature T Date
Please check applicable subcontractors and complete the following information:
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Owner/Contractor ignature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Cry z pg 4; /0-S
Owner/Contractor ignature Date
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CITY OF
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
oS�6c,
APN #
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Date: G/� lOs
Building Address:
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PLUMBING
Owner's Name: n(�
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Phone
rqDF)L52-$z!S'7
BUSLIC
Business License
BUILDING
Contractor:I n
W
Phon
k,,) 33s-59ItG
License #:
3"74573
Contact:
Phone: S
Cupertino Business License #:
Building Permit Info:
Bldg ❑
Elect ❑ Plumb
Mech ❑
Job Description:
Residential
Commercial ❑
Cost of Project: i
12-00
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑
Re
lacement-�L
Qty. if
Applicable Fee ID
Fee IlPcrrintinn
I BPWHEATER
Water Heater / Vent
BUILDING
1 PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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