04080165 M101 WAIG
CITY OF CUPERTINO +£ °^° 4 + '�>at7�,: , $:r x,•"� , Wil 1,01'Uns "
BUILDING DIVISION PERMIT dCO_.1'TRACTOR INF ATION '
BUILDING ADDRESS: DAHL PLUMBING CO, JOHN F PERMIT NO,04080165
OWNER'S NAME: PERMITIBBUBDATE
HENRI BERGER '411>q ATMA ST A911012
ONE: SANITARYN ONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Yd LICENSED CONTRACIDR'SDECofCON NgLED
6 I hereby affirm Nn 1 nn ONTRA under SProvisionsD LA of Chapter Y(commencing Job Des I
with Section 7m))of Division Sof fie Business and Professions Code,and my license is
n s in full to=and effect.
jNZ LiccnmClav Lk.N REPLACE WATER HEATER
nDatecimsums,
ARCHITECTS DECLARATION AUG ZS 2004
1 understand my plans&hell W used as public records
ZX Licensed arch ionto BUILDING
3 OWNER-BUILDER DECLARATION
K O O 1 hereby.Titre than I ore exempt from the Contncmla License Lew for Nc
i a o following ricrac permit
t ]fon s r Business and improve.
de ons Code:Any oily or county
+�$us which mquias a permit an consuun,altar,imrrmve,h Permits,or mpalr any umcmm
F y pow miu Wancc,also
uantto are beapplicantof forsucthe Cianonrmirm Ncasigned momem
�<
that(commencing
comma Hermand pursuant to Ne of Divisio of of mBuinessa Ld Prof Law(ChanWr9 Sq. Ft. Floor Area Valua[io
(comma,atempt ssocSection70ndth basisofr of NCeged Business and Professions Any
Code)of
Net i is 31.5 b Ncm(rom and the bur far bj alleged exemption.Any l penalty
of
no, a 7031.3 ns atry red dont far a parrot mbjtta the apPliant m a civil peulty of 3&W NoBalgir 0 0 Occupancy e
not more Nan tiw hundred dollars(f300). � � P Y 1YP
❑I,utiwnaofthepmpeny,mmycmployseswlthwaguu Neirmleampenadon,
will do Ne work end Ne&mmurt is nminanded oro@red forsate(Sm.7044,Business
and Profess ons Code;The Commcmfa Liaise Law does not apply m an owner of Required Inspections
propenywho builds orimpmves wren,and whode asuch work himselforthmugh his
awn employees,provided that uch improvements an,not intended animated forage,It.
however,the building or Improvement is mid within one year of completion,the owner-
bullder will have an,burden of proving Nat he did at build or improve for purpose of
ale.).
❑I,as owner of the property,am exclusively contracting wit licensed anmum,to
convect to project(Sec.7044,Business and Professions Code:)The Comracmfs Li.
cense law does not apply in in owner of property who builds or impmm Merton,and
who mntracu for such projects wit a conuacmr(s)licensed pursuant m the Contractees
License Law.
0 Iamdsemptunder Sec. ,B&PCfortrrrason
Owner Date
70311WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
1 have and will maintain a Certificate of Cement to self-insum far Workeb ComKn.
f
ion.u provided for by Section 3700 of the Labor Code.for the performance of the
or which this permit is issued.
ats and will main an Worker's Compeuuion Insmana,as required by Section
dm lobar Code.for Nc pcifortnmen of Ne work for which this permit is issued.
y Waukee,Compensation Inmrance terrier and Policy number tae:
rtier. Polley No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thismctim nand not M completed lithe permit is portion hundred dollars(Sim)
or less.)
I certify dot in the performance of the work for which this permit r issued,I Mall not
employ any perms in my mmmrso a to become subject to the Warmos'Compensation
Laws of California.Dere
Applicant
NOTICE TO APPLICANT:IL after making this ComicaW of Exemption,you Mould
become subject in the Worker's Compensation provisions of Ne Labor Codc,you a=
.JO forthwith comply wit such paramount or Nm
is permit shall be deemed reversed.
Z^' CONSTRUCTION LENDING AGENCY
Fw� L hemhrmmNat Nemiso couuunion lending agency l'nr Nc perfurmuwc of
Ne work for which thio permit r issued(Sec.3097,Civ.C.)
0.Q Lenders Name
Z lender's Addm..
U Q 1 artily not I have rad this application and sac that be above information r
L4 H Cortaro.I agree to comply with all city and county ordinances and&tam laws adding res
O U building construction,and hereby mutation mpresenutives of this city to enter upon the
07 aMve.ms,judg epropcny far Inspection purposes-
04 (We)agree m ave.indemnify and kap harmless be city or Cupenino against
h in
enceofno,emaang expenses which may In any way eccaa ageiutaid City
t.1 7 A consequence of the UNDERSTANDS
of this permit.
Fi APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. s4ta�
Re-roofs
Signature of AppliamOContracmr Dean
HAZARDOUS MATERIALS DISCLOSU RE Type of Roof
Will the applicant or future building acupanwnm or handle hrurdous material
as defined by the Cupertino Municipal Cade,Chapter 9.11.and be Health and Safety
ade,Soctim25531(a)7 All roofs shall be inspected prior to any roofing material being installed.
r-1 your ❑No
If a roof is installed without first obtaining an inspection,I agree to remove
Wilt the applicator or nus a building by the Bt y A .Air Qu or devices which g
I,Daniel? us air contaminants u Uctincd by the Bay Area Air Quality Managcmcnt all new materials for inspection.
Disuin7
❑Yes ❑Nu
thrive mW Nc War ousm=6&ismquimmenuunder CTapmr6.95afthe Califon
nia Hslth&Safety Cade,Swc ms15M,15533and 15534.1 underaaM Nat ifte building
dos not currently hos a Wagon.Nat it is my msfembiliry m noul'y the occurrent of the
requirements which mug be met priormWuanceofacmtirwamarocapeacy. Signature of Applicant Date
Owner araalhari&edagent Di I All roof coverings t0 be Class"B"or better
d
c) CITY OF CUPERTINO
WATER HEATER 8
CUPERTINO PERMIT APPLICATION FORM
APN# A Date: —/3
—OV
Building Address: - I
Owner's Nam : P a#:
2-S-3-- 0�
Contractor: Phone; License#:
Kh, LC a �Yi -lam o
ConPho : Cupertino Business License#:
s
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ® Mech ❑
Job Description: // /
(Gc� C7 !tee
Residential [�J Commercial
Cost of Project:
0�
Strapped Li On Platform U Bonded ❑
New Location ElReplacement
. i
A lic le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERN=E Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
677
FW—,
TY OF CUPERTINOE
BUILDING DIVISION PERMIT �CO,NTRA.CTQR INFORMATJON'
DINGADDR�SS: DAHL PLUMBING CO, JOHNF PERmITrvo0408016S
. 297 NnRTUPROOK SQ
ER'S NAME: PERMIT ISSUE DATE
HENRI BERGER 399 ALMA 9T
NE:
SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDINGPERMIT INFO
e LIrAIV - LUMB MECH
ilo0 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal 1 am limned under provisions of Chapter 9(commencing JO Desc tl
n< with io IXXO of Division]of Ne B�usinw� (essioa Cade.and mylicenseb
in fullfo andcffe �Lk.M AUG 2004
^�z u+mn�c r G REPLACE WATER HEATER
_ ARCHffELTSD rl BUILDING
I i,u Mrd my plans nhall be used u pu ads
OyU s1��
3
'OG Liccnmd Profcuional
I OWNER-BUILDER DECLARATION
i m I hcmhy affirm that I am ucmpt farm M.Cannula,"Uccle law for IN
E:00 following meson.(Section ID]1.3,Business and Professions Code:Any City or county
31ai which acquires a Permit to cnmtruct.else,Improve,demolish,nr repair any structure
HZ Pries to its issuanec,alm requires the applieanl for such Nrnil on rile a signed statement
ss G
Mar Mislicensed purtuamtoMoprovisional(if MoConar torsLianulaw(Chapter9 Sq.Ft. Floor Area Valuation
e' $ (commencing with Stmlaa?").1 Division]of the Business and Professions,Cade)or
b set M is eumpt therefrom and Ne bub far Ne alleged mempsian.Any violalfon of n.n�
Section 7031.5 by any Applicant fora the permit subjects applicant to a civil penally of 3.Y Ui�WtSt�gfOO Occupancy Type
las moa Man five hundred dollen $500).
❑I,saownerofthe Property,army employees with wgesutheirmle ampensation,
will do Ne work,end Ne swnua is nmmtended M.Ifcred farmle(Sec.]nth,Business
and Profelaloe Code:The Contracmrs License Law does not apply to an owner of Required Inspections
Pm pony who builds or i m proves Iherea n.and who dart such work hurrartifor through his
Man employers,provided that such impomen is as not intended oroRered for We.IL
however,the building or impmvemem is sold within ON yev of compledon.Ne owner.
builder will have the burden of proving Nat he did ant build or improve for purpose of
ulcJ.
❑I,as owner of the propsnY,am conclusively contacting with licensed contraction;to
coruwcl Ne project(Sec.7049,eusinces and Professions Cade:)The Comnacusri Li.
sense law does not apply to an ower of property who build.or improves Neuron,and
Who anmcm for such projects with a contractor(s)licensed pursuant an the Conncmri
nu law.
esempt under Sec ,B&P C far Nis mason
:or Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of adury arc of the following dalantions:
1 haw and will mninuin a Cenlfita o of Consent m el(-insure fa Worker'sCompany.
satian,u Purloined for by Section 37p of Ne labor Code,fa the Performance of she
work for which Nis permit is iuued.
❑1 have and will mainson Wakcrs Compensation Inswance,as Featured by Section
7]00 of the labor Cade,for Ne Perfmmancenf dm work far which this permit is issued.
y Worker's amps ad.&O.N.carrier and Pol'ic'y a/upbar are:
m [ Panty rvq.;i lis 2211
CERTIFICATED EMPr1oN MWORKERS'
COMPENSATION INSURANCE
(This salla need not N completed if the permit Is for one hundred dollars(51(X0
or leu)
1 certify that in the Performance of de,work for which We amtit is issued.)shall not
employ any Italian in any mannerm as to become subject o the Workeri Compenudon
laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should
Warmer Subject in the Worker's Compensation provisions of the lahor Code,you must
QQ foMwith comply wishioch provisinm or this permit shall W decreed resulted.
z N CONSTRUCTION LENDING AGENCY
(~ 1 hereby of ion Nat dca in coneyou dnn lending agency for Ne performance of
fYi Ne work for which this patois b issued(Sec.3097,Civ,C.)
G0 Lender's Name
Z Lenders Address
U 1
t.7 Q I unify that I haw sad this city
and
and slate that the above information in
lL (~ wilding ague to comply with all city sed county nisorm of and sum laws slating e
QO bu0dingcoauuction,and hembywNorimrmat tlws of this city menarupon Ne
W ahew-men0onea propertes.,yo for aspartame
which
may
4 (We)agree tu on.Indemnify and kap humleu The City of Cupcnlno ageimt
(n in Consequence
of tts,cosu and expeis permit. may in anyway accrue against said City
in cansegnenee of the granting of This permit.
APPLI,ANT DERSTANDS AND WILL COMPLY WITH ALL N DINT Issued by: Date
L ��
£�- /�I=oy Re-roofs
Srgmsre of ApplirnnVCUrlracmr Date -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will 1h applicant a forum building acupanl gore orh.ndle hvsNous ma¢rial
C fined by dx Cupertino Municipal Code.Chapter 9.13.and The Health and Safety
ale.setas 35s]3(a)? r All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant or future Wilding aaupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Plant holoaom air comamirunss as defined by the Bay Arta Air Quality M...gement all new materials for inspection.
District?
❑Yes NNh`
1 have aced Ne haaamnal mgerials requirements under Chapter 6.95 of The Calif.,. /1
nine Horo&Safely Coale,Satiau 35505,3]53]vu135334.I uncconand da if the Wilding Com_
der t curmmI haw a nanL Nal it b my responsibility to nodlY The occupant of the 6�JCdJ
req w r to mar toissuanaafaCc '2tcofOccupanO Signature of Applicant Date
6
owaroraultionrraagent Date All roof coverings to be Class"B"or better