05040019 ;.CUILDING
TY OF CUPERTINO .'^
BUILDING DIVISION PERMIT CONTRAGTORINFORMATION';;v
ADDRESS: PERMIT N0.
ALL VALLEY PLUMBING 05040019
AM PERMIT ISSUE DATE
NE: DRAPRjG?j DR SANITARY OL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
20o LICENSED CONTRACTOR'S DECLARATION
0 0 0
wp I hereby arfrtm that I am I.aucd under provision of Chapter 9(commencing Job Desert 1 O ��
iW with ECI erebya Tin OtIso lithe Businder P,Ofmprevision
Codc.a9(com enci is FI
^tea in full force and of
5gi Licenmc liED
n.• 9� REPLACE WATER HEA
TER
n F w Dare @ntrmto
Y ARCHI'IECI'S DECLARATION
Y
,:1 1 undersand my plana shall Ise used a public rernrds 205
6
Licensed Pnsfessional ,
OWNER-BUILDER DECLARATION BUILDING,I 1 herehy af0rm Net 1 am exempt fmm the Convector's License Law for the
0 0 following mane. etch t 71Y1son Business and P,c,deruns Calc:Any city orco I..
V which its isex a permit re quires the alter,improve demolish.ries sir ed svucmre
in Ooi at
et its sensed p,alsum to the thovisiosofcant On for such Contrarmitm rilcame Law(Chapter
in (commencingwJpunuart7")ofDivision3ofteBottomrindPrYLaw(Code)or Sq.F[. Floor Area Valua[io
nth$ (commencoem withSteuartand
the
basis for
of she Balneaandon.Myvi Code)or
Nat o is exempt therefrom and the bas.for the alleged eumant in Any violation of
Section 7Om by any red doll ror•permit subjects the applicant w e civil penalty of
not more man Bw hundred dollars(5500). 31V1yj)1HJ*4C0 0 Occupancy Type
❑I,as owner ofthe property,or my employcm with wages a their We compenadon,
will do the wart and thestmclu c is not intended m offered innate(sttJOaa,eosin...
and Professions Code:The C.to s License Law does not apply to an owner of Required Inspections
property who buildsor improws thereon,and who doessuch work therefor through his
own employ=,provided mat such improvements the notinlended or offered for We.If,
however,the building or improvement is mid within one yeti of completion.the owner-
builder will hive rise burden of proving mat he did not build or impmw for purpose of
We.).
❑1,as owner of the property,am exclusively contruring with licensed contractors to
construct the project(Sec.70",Business and Professions Code:)The Contractors LL .
cense law docs not apply to an owner of property who Wilds or improms thereon,and
who contacts for such projects wish a rnntrsctor(s)licensed pursuant in the Conuscmfs
License Law.
❑1 am exempt under Sec. .B k P C for this rtamn
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under perm of perjury one of the following declamations:
1 bow and will maintain a Certificate of Consent to self-insure for WorkcYe Comptes
anon,as,pmvidcd for by Section 3700 of the labor Code,far dm performance of ft
work for which this permit is sound.
1 ban and will maintain Worker's Campnwtion Insurance,ar required by Section
700 of the labor Code,for the performance of me work for which this Permit is issued.
My Work! Cpmpens tiara Insure ce carrier and Policy be art:
Carnetlsb4lli
Policy Na.:
CERTIFlCA OF EXEM MON FROMRKEO RS'
COMPENSATION INSURANCE
(Thirsted.reed not W completed if the,Permit is Forane hundred dollen($100)
in less)
I cenifv mat in the performance of thc work for which this Permit.issued,I shall not
employ,any person in my mmmrm as in become subject to the Workers'Compensation
Laws of Criifomia.Dam
Applicant
NOTICE TO APPLICANT:If,&for making this Certificate of Esc notion,you should
baomc subject to the Worker's Compensation previsions of she Labor Code,you mat
.J O foMwish comply with such Provisions sh
or this permit all be deemed tewked.
z h CONSTRUCTION LENDING AGENCY
I-+ I hereby alarm that inert iso construction lending agency for the Performance of
C the wvrk for which Out permit.issued(Sec.3097,Civ,C.)
Q lender's Name
.7. Z 1<ndch Address
Y,Q 1 certify mat 1 hunt read Nis application and sex¢mat the chow information.
Fcorrect.I agree to comply with all city and county ordinances and atsle laws misting m
Q V Wilding construction,and hereby authorise tepressentatims of this city In enter upon dm
ahovomenudgm property fm inspection which m.
F y (Wc)agree to saw,indemnify and keep harmless the City of Cupertino against
f/) incoiva,juce of th.catsand expenses;which may in any way scenic against said City
V z AcPLIC NT NDER TAN of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EGULATION
g Re•roofs
signature of Ap y ���anVConvacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant a futureW ilding oceupmt store or handl,haalloa mncrod
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Ouon25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes �a
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haardous air contaminants a dcfned by the Bay Area Air Quality Management all new materials for inspection.
vin? g�
0 Yca as
I have read the hvanienss materials requirements under Cbapmr 6.95 of the Califor-
niaHalth&safety GOdC,6'l%tiOns 25505,25533 and Z553a.l undcrsmrW thuifshc Wilding
does not cwrtndy haw a teen,that it.my respomibility m notify the occupant of me
reyuiremcm hicnmttuWmetpd oisumccoraccmncatnof funny Signature of Applicant Date
owner ar amanzea, L D,� All roof coverings to be Class"B"or better
F Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
91UPEkTINO
Building De artment
JOB ADDRESS:�d PERMIT # OO
OWNER'S NAME: !'-wMds Ad-i-n ONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors.
Signature Date
Please check applicable subcontra rs and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
:T
• Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbirig
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER b S�� v G
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building ddress:
Owner's N X
�'r cJ vsf
Con Phone a� /� rcense #:
Conta / J Phone: p Cupertino Business icense#:
/ D 4
Building Permit .
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On Platform Bonded
• New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING