05020151 CITY OF CUPERTINO
BUILDING DIVISION ,PERMIT4CONTRACTRINFORMATION ;°
BUILDING ADDRESS: HOT WATER INC PERMIT Nb5020151
s OWNER'S NAME: PERMIT ISSUE DATE
wir ONE: SANITARY NO.IQ CONTROL NO.
(6SO) 298-8494
ARCHnSC(ENGINEER: BUILDING PERMIT INFO
^BLDG EO PLO MO
!!0, LICENSED CONTRACTOR'S DECLARATION R /
w p w 1 Mmby arms"
Nn I am licensed under pow�isions of Chapter 9(commencing Job DescriptronY �f�/I �s
i rN Section]gkl)of DiviaionJof die Businrssand Professlun Coca.aM mYlittnx la r/ 1%
^Z.
'q= in full force and effett
3tr\'JlJb h(/S/A"
5LkenxC ' Lic.g 7 3(o k REPLACE WATER HEATER a
nF p Dow Consncar -
Al.h.11 CTSDECLARATION /A
� 1 undersand my plans shall be used u public teenrds `///Y[,/(A p _
7 w //V/J�///yya
x.G Licensed Professional
3 OWNER-BUILDER DECLARATION
00 1 berebe affirm on 1am 1. .rumps from Me Cononcats License Law for the
my ��
S:
O O following roasan.(Section]m1.5.Bniness and improve.
Moron Code:Any city os county 0❑1,
y$ which inquires a Permit to a ices th t aloe,improve,h Per i h,or repair any structureDIAprioaits sensed notiontto Me rovisi ia.f for mchpermita files Law(Chapter
fro (commiaranxdpaection7 )pmviaioMnfineeBusinar:un.ssimsCap r9 Sq.FLFloor Area Valuation
te59 Oat
is exempt
basis for
M the Business and Profession Code)or
Nes Section
is campy Ncmfrom and the beer for be alleged exemption..Any violation of
no' on]h L5 by Ory red oll fora permit subjects Nc applicant a a civil pcnafty,of 3 5a�EN Nuhibe0 0 Occupancy Type
not mom than foe hundred dollen(gem). P y YP
Q 1,u ownv of yk papery,or my employcn with wgu ss the'v sole eampensation,
will do Ne work,and theatronum u rat immncad w offaxd forsake(See.JBN,Bus users
and Profession Coda:TitsConuanofs Licence law don not apply in an Owner of Required Inspections
propenywho Wildsmimproves thereon,and who docssuchwork himself or through his
own employees,provided Nay such improvements are not intended oro@red forside.It,
however,the building or improvement is sold within one year of completion,Ne owner
builder will have the burden of proving Nat he did not Wild or improve for purpose of
ale.).
❑1,As Owner of Ne property.am exclnively contracting with licensed com sews s to
construct Ne proj.n(Sec.]Ore.Business and Profesmus Code:)The Cmanwari Li.
cease law does nos apply in An owner of property who Wilds or improves thereon,and
who comms for such projects with a conoacar(s)ficensed pursuant in the Convenor's
License law.
❑1 Am exempt under Sec. ,B At P C for Nis arson
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aft,.under penally of perjury aro of the following declarations:
1 have and will maintain ACertificate of Cmacm to self-insure for Worker's Co.,..
7U3373700offfic
tion,As provided for by Section 37M of the Labor Coca,for the Performance of Ne
workforwhich Nis permit is issued.
2'<have and will maintain Worker's Compensation Inuanrs,u required by Section
labor Code,for the performance ofthe work for which this Permit is issued.
y Worker's Coompensation Insurance carrier and Policy number are: 1((llrrier: FL4 a A Policy No.: /5y�93, ,
CERDFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aecum need not be completed if the Permit Is for one hundred dollars(gym)
class.)
I eenify Nat in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner in As In become subject o the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this CcniOate of Exemption,you should
biennia subject to the Workefs Cnmpcwuon provision of ado LAW,Code,you moa
wJO foMwith romply with such provision Or this permit shall be domed Invoked.
Z y CONSTRUCTION LENDING AGENCY
["+ l hereby affirm Nat Nem is a construction lending agency for Me performance of
FL> Ne work for which this Permit is issued(Sec.3M.Civ.CJ
UJA landcr's Name
Z) Z lender's Add. /J,'/,-�✓/i//1 /(\//
0 Q I certify Nat 1 Ague mad Nis application and au¢Nat Na above laws
upon i
t¢.F comeel-1 agrm a comply with all city and county ordinances and state laws relaing a
QU abon-gcaicried ion,end for by impaction purposes.representatives of Ni city manor upon Ne
slave-mcnuoned property for irupenion Purposes.
H 6 (we)agree a save,indemnify and keep harmless Ne City of Cupertino against
Z inconsequence ams,of
granting
uind expcncemit. may in anyway accrue against raid City
t) ,'� inconsequenceUNDERSTANDS
of this Permit'.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
� d;?/
Signatumof Apphse
eanVOmuae I Dane Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ute applicant or futon Wilding pecupamtsore AT Mndle owforma niamriA
j1lhLas deemed by tCupenind Municipal Code,Chapter 9.13,and the Health and Safety
ode,Section 25533(e)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
t�
Will Me applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit W.O.air cpmxmin.ma as defined by the Bay Area Air Quality Management all new materials for inspection.
DisuicG
❑rs CI
I have mal the hm d(iusmawrialsmquirementsunder Chapter 6.95ofthc Califor.
riaHmM&snotcu ntlyCode,Secuon.-lili3553=Wui53a.lundersand Net iflM Wilding �% _ 7 A
reqs not cumcndy M1vve a tenant Net it is my raapomiM1ilily m nosily the occupant of the --aL�t��(!�P/),u�� V
reyuiremcnts which mus}be 1priorsissuanceofa Ccniucain oroe
cppa¢y.
�2 3/�2alx Signature of Applicant Date
wnertenth...xdagant 1 Date All roof coverings to be Class"B"or better
Community Development
J 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�
CITY OF Fax(408) 777-3333 UPEkTINO
Building De artment
JOB�l,�SEInonrov« Sf. ( & rfi,10 /� PERMIT D�2016�
OWNER'S NAME: /YI M6,L. Lal' PHONE # 'f0$-&O-5 `15 53
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following 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 -ler Inc, 02/,3//
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
0" ,- -
Owne �- n-tra r Signature Date
CITY OF CUPERTINO
WATER HEATER 6 S-`' 2-
° S I
CUPERTINO PERMIT APPLICATION FORM
APN# 0 30 Date: 2 d O IA-
Buildin Address: l!/ J
3/SOS /nDaJrOU/Gc 6-& C 2�vf/h b c/ Sv/
Owner's Name: Phone#:
mnl7a, IlDy-
Conqactor: Phone: License#:
/to 1- C, I&D -&31- 5 -76, .3 to/o�-
Contact: // Phone: Cupertino Business License#:
r,b Gc vac &JD - CJa 5;
Building Permit Info: _/
Bldg —❑ Elect -❑ E Plumb - Mech ❑
Job Description: lCr Ik gym G /�(
��.� �lUa. 7-rt-�-
r S - S
Residential Commercial ❑ 7 r GX C/!off
Cost of Project:
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if - - --Applicable 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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