04030181 CITY OF CUPERTINO
BUILDING DIVISION PERMITdd� � M,tI�l�"'°'
BUILDING ADDRESS: PERMIT NO.
HOT WATER INC 04030181 '
OWNER'S NAME: PERMIT LSSUEDA'IE
12 4 12
ONE: SANITARY OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o o LICENSED CONTRACTOR'S DECLARATION "- - --Job Description
1 homby ROrm that 1 me licensed under provisions of Chapter 9(commencing
with Section 7000)of Division Sof Je Boamem ash Professions Code,and my license is a�t{�n s.-:_
'Pa infull cora and cnec (o3caia REPLACE WATER HEATER r� 7�E[�'
Z Z MM
License 1 Cong
p Dak RCHRECI'S DECLA ATION AUG 26 2004
WW7�7t 1 uMcnund my Diens shall M useJ u public mcnNs
� U
is Cleansed Professional BUILDING OWNER-BUILDER DECLARATION BUILDING
F.aY I hem er .(fuse That 11. exempt from the COnion Co :Any c Law for the Ad
p O following mown. (alit t 7031.5,Business and ve,Profession demolish,or:Any city m county
w$ which mqulrcs a pcmit re cores the sllee improve, ermttor repair any structure
u�'^
prior to issuance,also requires the applicant forsueb permit to Ole esigncd atskmem
that he is licensed purmanunthe provisions of the Contractors License Law(Chapter 9 Sq.F[.Floor Area Valuatio
(Commencing with Section 7000)of Division 3 of the Business and Professions Code)or
$ that be It exempt therefrom and the boo for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the appliant to a civil penalty of 3 0 Occupancy Type
not mom than five hundred dollar(g5M).
C I,as owner of the pmpmty,or my employees with wages as their sale Compensation,
will do the work and the structure is not intended or offered for at.(Sec.7041,Business Required Inspections
and Profession Code:The Conuucto's License Law does not apply m an owner of q P
property who builds orimprrves thercon,andwho doessuch work himselforthroughhis
own employees,provided that such improvements am mduanded mattered formic.IL
however,the building or improvement is old within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
role.).
❑1,as Owner of the property.am exclusively contracting with licensed contractors to
Construct the project(See.7044,Business and Professions Code:)The Contraeurs Li.
came Law does not apply to an Owner of pmpa rty who builds or improves thereon,and
Who contracts for such projects with a contramor(s)licensed punuantu the Contractors
License Law.
C lamuemptunder Sec. ,Bk PCfmthumoon
Owner Dak
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations: '
I have and will maintain a Certificate of Consent in self-inure for WorkersCompa-
ration,as provided for by Section 37M of the Labor Code,for Ne performance of the
.it for which this permit I.issued.
dl.l have end will maintain Workers Compensation Insurance,as nequircd by Secdon
�0 of the Labor Code,for the performance Of Ne work for which this permit Is issued.
My Workers Compenation losunncc artier and Policy num db-Brent' ���
Cartier, ST/4TF i'LA O Polity No.: -I
[J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sabon need not m complekd if the permit is form=hundeeddollars(SIM)
or leas.)
1 certify that in the perfnrmanec of the work far which this pennh is issued,I shall not
employ any person in any manner m u to become subject to the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions Of the Iuhm Cnde,you must
,J Q forthwith Comply with such provisions or this Permit shall be deemed revoked.
z r~N. CONSTRUCTION LENDING AGENCY
[-t I hereby affirm that dem is a construction lending agency for the performance of
tYi> the work for which this permit is issued(Sec.3097.Civ.C.)
W Q Lender's Name
z Lenders Address
V Q I Certify that 1 have read this application and state that the above infmmniun is
F correct.1 agree to comply with all city and county ordinances and nuts laws relating to
0[J building Construction.end hereby munire reprommooives of this city to caw upon the
Lau shove-mentioned property for inspection purposes
(We)agree to rove,indemnify and kap harmless the City Of Cupertino apiot
cdp liabilities,judgments,costs and expenses which may in any way acnm against mid City
t„)7 in consequence Of the gnnung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
soukcE U TI S.
x (�
Re-roofs
Signuum ofADDlicaCo Data-
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
WIII the applicant Or(Muni buildings.Chantstoveor handle Hut ad
o Ocftned by the Cupertino Municipal Code.ChaPkr 9.12.and the Health roil Safety
Code,section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
CYes ON.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haanime air ccomarimnu as de0ncd by the Bay Arca Air Quality Matti all new materials for inspection.
Diurin7
C Yes ON.
[have mad the huardousinakriais mquimmenm under .Chapter G95 of thc Califor.
ni.H ] ilk SefctyCOM,Sccdom25505,25533and25534.1 ackeand thatifthe building
does not curmnsly ham a kmnk Nat it is my remonsihility an notify the..Pat of the
requimmc 'cl}{nua/p,�met pilar to mashce eracen;Bcaa:of Ocaapry�,,/ Signature of Applicant Date
�+ �/ S C,/
L All roof coverings to be Class"B"or better
Owner or amhonacd agent Dsk
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT# O
/ 12 /217 �iZ fT rx. 64 olgl
OWNER'S NAME: Z>4 PHONE 1, 631
GENERAL CONTRACTOR: k1C 'pwC FAX # So '
I am not using any subcontractors: 63 2 O
Signature Date ,
Please check applicable subcontractors and complete the following information:
60 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
Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPS OF
PERMIT APPLICATION FORM /
R.
APN# 55(�) -Z(4r -C) C2 Dater
BuiAddress:
ldin
5 Mt. Cir fi �Ia2sL�
Owner's Name: Phone#:
t c�ke �- Sc � (k Take- ( o )zss- 3
Contractor: 963 I HOT WATER, INC. Phone: (05 _ 03'-gt7g icense#:
-7(o 3� 1
Contact: bAN CARLOS, CALIFORNIA 94070 Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb CJS Mech ❑
Job Description: t rot, , �/Lafer
Residential Commercial(meJrcial ❑
Cost of Project:
Strapped On Platform $onded
New Location El Rep lacement sQ/
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