04020070 CITY OF CUPERTINO
BUILDING DIVISION PERMIT , t~`U ?TI�AGTO�2INFORMATION'
BUILDING ADDRESS: PERMIT No 04020070
OWNER'S NAME: PERMIT ISSUE DATE
MALISON J
ONE: SANITARY NO. CONTROL NO.
ARCHITECUE.NGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 LT t�
+JOp LICENSED CONfRACIDR'SDECLARATION Job Description
d F 1 hereby affirm that 1 an licensed under provisions of Chapter 9(commencing
`0 with Section 7M)ol'Divlaion 3 oflha Business and Professions Code.and my license is
'A�81 inmRf....deff«t. REPLACE WATER HEATER
Z License Class Lic.k
vii-p Data.Contractor (30 GALLON)
,4 ARCHITECTS DECLARATION
ooZZ 1 understand my plans¢hall be used as public accords
30 t; Licensed Professional
SOWNER-BUILDER DECLARATION
I hemby offtrm Nm 1 am exempt from the Contractors License Law for the
no fallowing reason.(Sectimt 7031.5,Business and Professions Cade:Any city or county
se S f which rasp.ma•Permit to cannmct,slue improve,demolish,or repair any structure
ria prior to its issuance,also requires We applicant for such permit to file a signed statement
p 0
that he is licensed pursuant to the provisions of the Conlmum's Limn.Liar(Chapter 9 Sq.Ft.Floor Area Valuati09600
y (commencing with Section 7000)ofDivision3 of the Bumnusand Professions Code)or
Y
drum he is exempt therefrom u
and the basis far the alleged emptloa.Any violmum of
,ad.7031.5 by any applicant for a permit subjects the applicant W a civil penalty of APN Number Occupancy Type
oat roam than five hundred dollar(8500).
❑1,as owner of ifie property,or my employees wIN wages u Heir sole compensation, 31631040 . 00
will do the work and thestmctum is not amended oraffered tarsale(Sm.7W,Business
and Professions Code:The Convectors License law does net apply to an owner of Required nspections
property who buildsorimpmers thereon,and who doessuchworkhimselfor through his
own employers,provided that such improvements ere not intended oraQeed forsale.If. _nv,
however,the building or improvement is sold within an you of completion.the owner.
builder will have Ne burden of proving that he did Out Wild ar Improve for purpose of
sae.). X1491
1.e¢owner of the property,am uduuvely conuaning with licensed cantnclon m yrs
co......the project(Sec. Business and Professions Code:)TW ConincmrY Li / 90
cane Isw rims not apply m an owner of property who Wilda or improves thereon.and ♦- C oA
who Comment for such pmkcu with acomracmr(s)Iimved pursuant to tie Contractors VY
mLaw.
0
lam empt under See .B&PCfor Nis meson
WORKER'S OMPENSATTON DECLA4RIKION
1 hereby scams under penalty of perjury otic of the following declarations: -
1 have and will maintain a Certificate of Consentto self-insum fm Workers Compton.
sella.as provided for by Section 3700 of the labor Code.for the perfarmanm of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,se required by Section
3700 of this Labor Cade,for We performance of We work for which this permit is issued.
My Worker's Compensation Insurance cannot and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssecdon need not W completed if the permit is faro..hundred dnllem(SIM)
or less.)
1 certify Nat in the performance of Use work for which this permit Is issued,I shall not
employ any person In any manner an as to becomesubject to the Workors'Compenmdon
Laws of California.Dae
Applicant
NOTICE TO APPLICANT:If.after making this Ceniftcae of Exemption.you should
become subject to We Worker's Compensation previsions of the Labor Cade,you mum
Z forthwith comply with such provisions Of this Permit Mmtt W deemed mvoked.
„'Z,t O CONSTRUCTION LENDING AGENCY
[-r ren Ih..hy apron Out there is a coamuctinn lending egemy far the performance of
rli 7 the work far which this permit is issued(Sec.3097,Cih,C.)
GQ LerName
r0 z Lenders Address
U O 1 certify that 1 have read this application and sure that We above inforenadun is
IL,F torten.I agree to comply wit all city and county ordinances and Mute laws relating to
OU building construction,and hereby auNories representatives of this city to enter upon the
abon-mentioned property for inspection purposes.
tF^y y (We)agree to save,indemnify and keep homeless the City of Cupertino against
fA
liabilities judgments.costs and expenses which may In any way act.against said City
fJ`L inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CEREGULATIO S. e
Re-roofs
i mcof Appt M o for De
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the applicant or rumm building occupantstom or handle havardous material
a defined by the Cupertino Municipal Code.Chafer 9.12.and the Health and Safety
ode,section 25532(¢)? All roofs shall be inspected prior to any roofing material being installed.
0Yes bNu
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 hurardous air contaminants as deBncd by One Bey Ama Air Quality Management all new materials for inspection.
District?
0 Yet �No
I live nevi the hasmaus materials mWiemcnu under Chapter 6,95 of the Califor.
nix Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if Ne Wilding -
does not cuveady have a enana that it is my responsibility in notify Ne occupant of Nc
mqu' rocas which roam lmeL prior in iuuanfc ora Certifealc of Occupancy
Dae. Signature of Applicant Date
w t at aaNdri.d age., 41
All roof coverings to be Class"B"or better
CITY OF CUPERTINO
WATER'HEATER
CUPEkTiNO PERMIT APPLICATION FORM
APN# / O Date:
Building Address: /o (5
Owner's Name:
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
ResidenComm rcial El /
Cost of Project: /
Strapped LJ I On Platform El Bonded
New Location ❑
ReplacemoetN
Qty. if
Appfwable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMP iE —Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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