03080141 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTOR INFFORMATION Ek
i BVILDINGADDRESS: HOT WATER INC PERMITN003080141
owNR'SNAM 2531 GRACELAND AVE PERMrr kssue DATE
TRT TRAM /26/20
ONE: SANITARY O. CONTROL NO.
(650) 298-8494
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
i0o LICENSED CONTRACTOR'S DECLARATION
<wF 1 hereby affirm that I am licensed under provisions Of Chapter 9(commencing Job Description
SZwith SectionlON) of D' isionJof NC Bu in send Profcuinm Codc,and myliccnse is
in full fore.a Off
;�? L;cen L '. 3(pIZ REPLACE WATER HEATER FINALEM
Dam
Ft,J' ARCHITECTS DECLARATION - gg
IW underhand my plansshallbe used as public records SEP
°0 La,.medPmfu9ainral 2003
OWNER-BUILDER DECLARATION pp1�
a f 1 hereby affrm that 1 am exempt from the Cmimetor's License Law for the "ILDING
a O following reason.(Section 7031.5,Business and Podcadons Cade:Any city or county
m which requires a permit to construct,Macy improve,dcmulish,or repair any structure
_26
print(it its issuance,also requires he applicant for such permit m El...igned statement
that he is llecnscd pursuant a the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
2�O (cons shaming with Section 7")of Division J of the B usiness and Profcuions Code)or
that be is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any Affluent for apermit subje=tadue applicant ma=ivnPariahs Of APN Number Occupancy Type
'- not more Nen fnt hundred dollars(5500). --
❑I,u owner of the progeny,or my employcu with vagu u their ole compensation,
will do the work,and the struaum is not intended or offered for sale(Sec.7W.Business 502 - FINAL R&WMIlk4FIccE&3ERGY
and Pmfeismas Code:The Contractor's License Law does not apply to An owner of
.and
who builds or improves thereon,and who doessuch work himselfor through his 506 — GAS .TEST
own employees,provided that such improvements are not intended oroffered for sale.It. 5O7 — FINAL PLUMBING
however.the building or improvement is sold within arm year of completion,the owner.
builder will have the burden of proving that he did not build or improve far purpose of
1,as owner of the progeny,am exclusively contracting with licensed convectors to W - - - --- -- -
construct the project(Sec.7044,Busincu and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of property who betide or improves Lineman,and
who contracts for such projects with a contnnor(s)licensed pursuant o the Contactors
License 4w.
❑I am exempt under See. Bk PC for this moon
Ow r Da
WORKER'S COMPENSATION DECLARATION _.- .... -.
I hereby affirm under penalty of perjury one of the fallowing declarations:
„J I have and will maintain a CertiOcam of Consent
"self-ioum fur Worker's Compen- ..
`f cation,u p,.video for by Sation 3700 of the labor Code,for the performance of the
work for which this permit is issued.
kwe,!have and will maintain Worker's Compensation Insurance,o required by Section
]IOD of the Labor Code.for the performance of the work for which this permit is;uued.
My Worker',Compensation Insurance tinier and Policy number am,: }�1(
Carrie8 /-T I P fyf-'a7 Poli o.: > •C�3 V`r_
J/( CERTIFICATE OF EX EM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(This aesim,need not be completed If Lbe Irrmit is for one bundmA dollars(5100)
less)
1 ccnify that in the performance of the work for which this Permit u issued,1 shall not
employ any Person in any manner an ober become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifcate of Exemption,you should
become strocet to the Workers Comix a ration previsions of the labor Cole,you must
70 forthwor i Lh comply with such provisions ohls perm sh
it all he deemed revoked,
Z ryN. CONSTRUCTION LENDING AGENCY
1 hereby Affirm that there its construction lending agency lar the Performance of
Y, the Work far which this permit is issued(Sec.3097,Civ.C.)
Lcndcfs Name
Z Landers Addresa
J Q 1 certify drat I have read this application end sum that the Abom inromvadiun is
L•-' toren,1 agree to comply with all city cao
d county ordinces and nate laws relating to
J U building construction,and hereby authorim representatives of this city to Omar uponthe
wshove-mentioned property for inspection purposes. _
ypi, (We)agree to ave,indemnify and keep harmless the City of Cupenina against.
to liabilities,judgments,costs and expenses which may in any way accrue Against aid City 2
J7 in eonacqucnec of the granting of this permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE A N5, �v z
r a� ° Re-roofs
gnewm of ApplieeHAZAR O Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WILL the applicant or Tutus building occupant nor.Oran the
boaoh An material
As dented io the Cupertino Municipal Cuda Chapter 9.12.and Linc Hcelth and Safety
Cod.,Section 23532(x)? All roofs shall be inspected prior to an roofing material being installed.
❑Yes ON. P P Y g g
Will the applicant or mmm building Occupant as equipment rtdcvi=es which
-If a roof is installed without first obtaining an inspection,I agree to remove
It haamnm air contaminants u dcfnwl by the Bay Area Air Quality Management all new materials for inspection.
Miller
❑Yes ON.
I have mad the hmaNaus materials requirements under Chapter 6.95 of the Califon
ria Health A Safety Cade,sections 2M5,25533 and 25534.1 understand that if the building
te ,
does not currently have a tenant Jim it is my respunsiolity w notify the occulted of Ne
requircmcnu whi�ust be met prior to issuance of a Certificate of =spancr.Ole C attire of Applicant Date
�
Owner or audhorircd agent Oam All roof coverings to be Class"B"or better
CITY OF CUPERTINO /
3
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 6 Date:
v O8 2� 03
Building Address:
7S3( �1�iwl c�
Owner's Name: }t ne#
Tim rr , � Vel u�r vi y08) Zz,-
Contractor: Phone: License #:
2 Phi-eyp 1 -2& 361L
Contact: Pho Cupertino Business License #:
C'I. 2, ��s � l zea-8Y�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: �JJ
,foo
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. .
A I' a Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING