04050094 CITY OF CUPERTINO �v a a �s
BUILDINGDIVISION PERMIT t �+� V •0WINl'O
BuaDmc ADDRESS: WATER HEATERS ONLY PERMIT"D04.050094
OW NEWS NAME: PERMIT ISSUE DATE
DAVID CRTTQRR 970 R_ MATM ST STITTE 200
E: SANITARY"O. CONTROL NO.
,Ir (800) 835-5946
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 t
ycc LICENSED CONTRACTOR'S DECLARATION
(� 1 hereby affirm Net I am licensed under provisions of Chapter 9(commencing Job Description
witE Section 7")of Division 3 ofUc Business and Professions Cock.and my license is
"may in
fell fnrenantlefferLI 37t� Z
D4X LicenseClass WATER HEATER REPLACEMENT
6
1351 Dau IL'
ARCHnL77 N
1 understand my plans shall he used as public meet& /
JyU p
G Licensed Professional
3 OWNER-BUILDER DECLARATION
QI I hereby affirm that 11. exempt from the Commmors License Lew for the /
p O following mason. encuun]ID t.5,Business and improve,
de o demolish.
Code:Any city or county
�i which requires issuance,permit re enres the alter,imfor sur demolish,nr repair any awment
that heor its easedpurse pursuant
to the pre inion of the for such PermiLLoicensle ae Law
(Ch statement
E o (c.rumisliccnwJpumtion7 )ofDivision3offtButmet's License ..Chapmr9 Sq.Ft. Floor Area VaIU n
m $ (cat he
exemiNSediont and
III
Iv for the alleged
exempton.Any
Code)of
3.•
that he is exempt Nelefrom and the Eesti for the alleged exemption.Any viola0on of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 314a441Nk7193e10 0 Occupancy
not more than eve hundred dollars($5011). - e
�'P C]1,I,as owner of the pmpmy,or my employees with wages as their sole compensation,
will do the wad:and Ue swnum is out intended or offered fouale(Sec.71144,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of Required Inspections
property who buildsorimproves themon,and whodoessuch work himselforthrough his
own employees,provided denstch improvements art not intended or offered foraele.If,
however,the building or improvement is sold within one year of completion.the owner-
builder will have Use,burden of proving Nat he did not build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contmemn to
construct the project(Sec.7044.Business and Professions Co&:)The Contractor's Li-
cenae Law does not apply In an owner of property who builds or improves thereon,and,
who contracts for such projects wile a conexclor(s)licensed pursuant to the Contractors
License Law.
El lamrmtrinceder Sec. ,B&PCfofthisteaces
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
/ 1 haveantl will maintain a CeniRcate of Consent to self-insure for WorketsCompen-
\t nation,as provided for by Section 3710 of the Labor Code,for the performance of the
i. work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3711 of the Labor Cade,for Bre performance of the work for which this Permit is issued.
My WorkcrS Com motion Insurance carticr end Poliry nur9/bb m:
Comer: r5 t/» Poliry No.:. v s�Z�
CERTIFICA OF EXEMPTIONFROMWORKERS'
COMPENSATION INSURANCE
Crnle seciimt need not he completed if the Permit is forone hundeaddollare($1(g0
or less.)
1 cenify Beal in the performance of the work for which this permit is issued,I shall out
employ anypenon in any mannerso As m become subject to the Workers'Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT:IL after making Uis Certificate of Exemption,you should
become subject to the Worked Compensation previsions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed'rewl ed.
Z CONSTRUCTION LENDING AGENCY
[-ice I hereby affirm Beat there u a comtructinn lending agency un the Performance of
Ci the work for which this permit is issued(Sec.3097,Cih,C.)
V4 Q Lenders Name
z Lender's Address
U O I cenify Beet 1 have read this application and mute Beat the above information is
correct.1 agree to comply with all city and county ordinances and sura laws relating to v
V building construction,and hereby authorize representatives of this city m eater upon the
Uabovomentioned property for inspection purposes.
CL
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
iHs VO liabilitim.judgments.costs and expenses which may in any way accrue against said City
U in consequenc fUe Sraming of Permit / O
r-i APPLICA N ERS Nfpa$S D Wli�OMMPPUl'WITH ALL NON-POINT Issued by: Date
50 C S.�� S
7 ��ykV Re-roofs
Signature of ApplicaDateHAZA
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will its,applicant or future building uccupenlstorc orhandlc hayardous material
m dcrned by the Cupenino Municipal Code,Chapter 9.13,and the Health and Safety
ode,$action 85
El yes 32($)�]No All roofs shall be inspected prior to any roofing material being installed.
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
It W."Irus ai conlammanu m defined by the Bay Arca Air Quality Management all new materials for inspection.
Dislrin? `\
❑Yes �Nu
Ihavereadtheh=a (iusmamdalsmquimmenuunder Chaper6.95of Bee Califon
nia ell
building,
docs nal cuneedy have a evens Beet it is my responsibility m noul'y the oce.i ant of the
mquimun 'ch me be et issuance accnnficatcofoc P cy. -•Signature of Applicant Date
Owne a g Dae All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER
aCITY0
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
v
Building-Addres :
j -D Z -2-
Owner's
Owner's Nap Phone#:
Contractor: Phone: License#:
� 800 S-S�yb
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description•
Residential Commercial ❑
Cost of Project: IVO
/ddU
Strapped ❑ On Platform 0 Bonded ❑
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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