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05030104ZCZ LOC 'i=E 5q �f- s- D;2 . 0 ; i� ac yse rz> z z C F� aQ 7z UO_ OU U F� �z CITY OF CUPERTINO CONTRAR-1 NFORMAT-19N.�' BUILDING DIVISION PERMIT BUILDINGADDRESS: NnnNAN CT WATER HEATERS ONLY I'll No05030104 OWNER'S NAME: PERMIT LADE DATE ONE: SANITARY N CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH LICENSED CGNTRACIDR'S DECLARATION Chapter Job Description, 1 bemby Num Nat I am licereaudBu under provision of 9 (commencing with Divivion)of tm Buvncaaand Profeuionx Code. andmylicenu is � /� (�© in full force end ett llto=]deff License Clw e�'`3 f� Lie a REPLACE WATER HEATER 4' Dale Cu actor ' ARCHrp1IQM 7 N I understand my plana shill M4md u public records 1 APR -5Z2005 Q n� Licensed Professional OWNER BUILDER DECLARATION DECLARATION 1 hereby affirm this I am exempt from dor License Lew for Inc following mason. (Section 7031.5, Business and Pmfeasion Code: Any city or county which requires a Permit to construct, alter, improve, demolixh, or repair any structure U ��j \ s _c9 u u \!j p (\I\e� prior In its issuance, also requ ren the applicant for such Permit to flc a signed statement ,MI he u licensed purwant to the provision of Um Contractor's Limn, Law (Charter 9 Sq. Ft. Floor Area Valuation (commencing with Section 700(1) of Division 3 or the Business and Profession Code) or that M is exempt t ershrom and Ihe basis for the alleged caemplion. Any violation of Section 7031.5 by arty applicant fora permit subjects the Applicant w .civil pcnahy of 3 SRP.Q`6I3leo 0 Occupancy P Type not mom than five hundred dOlhm (SSW). Y ❑ L u owner wvgu u ttev compenation, the propene, m my emptencle oith . (Sec. will Pr the work. ands: em Contractor's intended, Law and Profession Code: The Contractor: License Uw don not apply lf an owner de for file(See.ho an Bumewneroa Required Inspections ertym whooves is g formedhootigh his chendewilling Wiprovid provided own employers, provided Hal such improvements tie not intended own ye o Such impr.endwho dorso w lli formed. If. however. the building orimprovement isSold mpletimd did one year or completion, the Owner. e Wilder will have tis: Wrdrn of proving IMI be did not build Or improve For puryose of sale.). 0 1. u owner of the property, Am exclusively contracting with licensed contracters b construct the pmjen (Sec. 7044, Business and Profession Cade:) Tice Comruwes Li. cense law does not apply to an owner of property who Wilda of improves Hereon, and who contracts for such pmjecu with a comractor(s) licensed pursuant an the ContracroYs License law. El am exempt under See. . B & P C for this mason Owner Dale WORKER'S COMPENSATION DECLARATION 1 hereby AM. under pera ty of perjury ..of the following declarations: 1 have and will maintain aCcil ficute, of Convent to self-insum for Worker's Compere cation, u provided for by Section 3'100 of Inc Labor Code, for the perfmmms aof the work for which His permit is isued. 1 have and will maintain Worker's w Compelion Incomes. u required by Section 3700 of He labor Code, for the performance of Ne work for which this permit is issued. My Worker'scurpRaMon Insurance carrier and Policy number am: Cartier. "'s� PolicyNo.:3S7 717v CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section recd not Irceomplmed if the permit Is furore hundred dollars ($I0i or Max) I certify that in He performance of He work for which this Permit is issued. I shall not employ any person in any manners AS w become subject to He Worker: Compcnstion Laws of Califomia. Date Applicant NOTICE TO APPLICANT. Jr. after making this Cenifince of Exemption, you Should became subject in IM Workeh Com'... provisions of the labor Code. you mu, foMwitc comply with such provision of this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby eRnm that them is a convection (ending agency for the perfortwnce of the work for which this permit I, issued (Sec. 3W7, Ci, C.) Lender's Name Lenders Addmu 1 entry that 1 have lived this application son scale Hat the erose information u carton. I agree to comply with all city and county ordinances of and sum laws relating e Movengconstruction.mimseand hem ax"Imntrzmprtsentatru of Hu city ad enter upon slat ahuve-mentioned Property for nL (We) agree w cave, indemnify and keep harmless He City of Cupenino against ooss 5/ liabilities, J andn which May rs which may in any way ucnv: vgviunild City u,cnu andOf in consequence nce Or dus this lll///!ll APPLICANT NDER `TAN S!th DWIreirmi AyD WILL COMPLY WITH AL NON -POINT SOURCE //� �ftr� Issued by: Date - OJ (/w^'V' Vg/V "TIONANOS %TION a Re -roofs 3/ / 5 Sign gum non r Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicano or future Wilding ottirpamatore or handle nacamouc muerial u defined by the Cupertino Municipal Code, Chapter 9.11, and the Health And Safety Section 25532(a)? C' -1 Yea All roofs shall be inspected prior to any roofing material being g installed. Will He applicant or future Wilding occupant taw equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove nharardmu air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. Disuin? [ot ❑Yes v -P 1 have rng om nuamou ooterials mquimmenuundc,CMpcer6.95ofIheCalifor- Oil Health&Sarcy Code, ScetoUVi50end 5.]5533 25534.1undnsung that iron Wilding does not currently haps a mount, that it is my mi mobility to nutily Ihe occupant of Ix, mynhmmen wmm�v mel toiAm acenifeale9rapay Signature of Applicant Date All roof coverings to be Class "B" or better own wautho acdegcnl % Dam I low, CITY 0, �UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: z �G �S PERMIT # 050 3 a 1) 4 OWNER'S NAME:` p t,�y, PHONE # S 7 — 9 Z qGENERAL CONTRALTO ¢ FAX # I am not using any subcontractors:a&41D S Signature Date Please check applicable subcontractors and complete the following informat;nn- Owner/ Contractor Sign e 3/V/� 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 qiw� Sheet Metal Sheet Rock Tile Owner/ Contractor Sign e 3/V/� Date • CITY OF CUPERTINO CITY OF CUPERTINO WATER HEATER o��3 PERMIT APPLICATION FORM APN # 7557- r 9- o `� `f Water Heater / Vent Date: 3, y os Building Address: PlumbingPermit Issuance Owner's Name: BENERGY Phone # Contractor: -F> _, f� Phone: X00 8,�s -s 9 �{ 6 License #: ,3-7 4 5 73 Contact: Phone: a -tea' Cupertino Business License #: 100566 Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: Lac c� '67-0 a o Residential Commercial E] Cost of Project: Strapped ❑ On Platform LJ Bonded ❑ New Location ❑ Re lacement/Ef Qty. if Annlicable Fee m BPWHEATER Water Heater / Vent BUILDING PPERMrrFEE. PlumbingPermit Issuance PLUMBING BENERGY Ener BUILDING BUSLIC Business License BUILDING 2,,�3S�