04050108/ CITY OF CUPERTINO
CONTRACTQRTNFORMATTON
BUILDING DIVISION p]•.RIVIIT
BUILDING ADDRESS:
HOT WATER INC
PERMITNOO4OSOIOB
pERMITLSUEDATE
OWNER'S NAME:
GRAIG REAND AVE SANITARY NO. CONTROL NO.
ZONE:
650 298-8494
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
:per
LICENSEDCONTRACMWSDECLARATION Job Description
ti 1 bm 7 al.f that 1 w Of
ft Bo under provisions of Chapser 9(commencing
ith ScI for by arof thatt I A3 of dw BdunmmARofmiof Codo,mdco menet is
r In Wild, emdefect. Can REPLACE WATER HEATER
Z License les C Lk.a �Liady
Oak AR Hf1ECI'SD CLARA I l, /
f undcraunJ my prem chart be used u public records ///---
w Licensed Professional
yC OWNER-BUILDER DECLARATION \
I bemhy.Rum that I em ucmpt from the Contractor's License Law for Ilk O
i O O following Munn.(Section 703 1.5,Business and Pmfmiom Cock:Any city or county
la ff which requires•pm ah m congmm,alter,hnpmve,do nallah,nr repair any nmcture
—�„ prior to its issum=,aim requites lM applicant for such Permit to file asignWgatement Ft.Floor Area Valuation
FF < that he is licensed pursuant to the provisions of NC COnIruwls License law(Chapter 9 SQ
y�$ (commencing with Section 7000)of Division 3 of Na Brsinm and Professions Coda)-1
g-
that
scan 703is xgaM 5 by any applicant for A permibunds it bjem the eppl curl to a vilny ipsm.hy of 3 [j"er0 0 Occupancy Type
not mom Nan free hundred dollen(5500).
wi Luownu of and
tirea",or myemploym wlNwguuOteirsol.7044.8 utlon,
will pr Ncwons end the shame Isnot intended orone do foracrepply 70dd,Business Required Inspections
and anywh bar Cade:The m Ate en. rad who Taw does at apply lf an owner
property who bui Ido or Ire prows Ther=n,end who d=s still work himself or through his
own employ=s,provided Nat such tmprowmmts are not Tear dedOf
m leand for mvoAT
however.Ina building orhnprowmentissaid withinman Year of completion,Ne owe of
builder will have Ne buAen of proving Nn he did not build or improv for Purpose of
..I.J.
❑I,As owner of the property.am ucheovely comraming with licaaaed"Ma acrms M
coutoact the project(Sec.7044,Business aha Profusions Code:)The ConrACMr"a Ll'
cense law docs nor apply w.n owner of property who builds or improves Neuron.and,
who contracts for such pmjccn with a=ntracmr(N licensed pursuant M tin Conlncuses
License law.
❑l am exempt under Sm. ,B&PCfor Nis noon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby ef1ml under peulty of perjury one of Ne following doe—tcu:
1 have and will maintain a COAWE w of Consent to Asir-Insure for Workcr'a Compcm
xoom,u provided for by Section 370 of the labor Cade.far the Perf=mrnce of the
W
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,u required by Section . .
or the labor Code,for the performance of Ne won far which this permit is asked.
My'
y Worker• Compemad..Insurance c.rrlmmd Policy number.¢:
Cartier, T/-1T/ f Uh/�Policy No.:
CERTIFICATE OF E%EMPr10N FROM WORKERS'
COMPENSATION INSURANCE
Ohisuction need no N completed ifft parait is fare=hundred dollars(SIM)
lat
1 ceAfy Net in the"fr rm.me of the work for which Nis Permit B issued,I.hail not
employ any penin in my manner m as M become subject he the Workeri Compensadon
Laws of Califomie.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificak of Eacmption,you should
become subject to Nc Workers Compensation pmvbdOM of the lahnr Code,you mug
�O foMwiub comply with such pmviaio=or NU Permit shall be deemed ranked.
Z y CONSTRUCTION LENDING AGENCY
1 bemby eRrm that Nen 4 a comwctinn lending.gency fm the pmfurman=Of
a r7 the work for which this permit is issued(Sec.3097,Ci,C.)
W QLmdefa Name
g'. Lender.Add.
U O 1 cenify Nat I have read this applicadom and auk Nat the.bow inform tun is
W F' conecL I agree to comply with ail city and county oNinuuss and sok laws relating M
p U building muwee re saw.
.rode nifygalAnd
eprtxn im of this city to enoing upon Nc
k1 .hove-mentioned property for inspection Purposes.
gy eWel agree M sew,indemnify end tech May
i m the City o(Cup 1fog-against
to liabilities,judgments.costs and expenses which may in my war'accrue egainstsaid City
Uz In consequence or the granting of this permit. Issued by: Date
n+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REG4TIp1gS. ��
.�11�//o OS"/91fJ('I Re-roofs
Signature of ApP rl caHAZARDO Dk Type Roof 9 A (��
HAZARDOUSMATERIALS DISCLOSURE yp l /
Will the Applicant or future building Occupant Stare or handle huarduus mawdai
As defined by the Cupertino Municipal Code.Chapter 9.13.and The Health and Safety
ode,scctiom 25532(8)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will the Applicant cor fawn building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it havardnua airirc=uminanu As defined by the Bay Arca Air Quuity Management all new materials for inspection.
Diudi,?
❑Ycs �u
I have real Ne bmaN=strawrlalemquimmen s under Chap nr6.95 of Ne Califor-
nia Health&Safely Cede,SOCti0u MMS.25533 and 25534.1 understand threif Nc building
does not currently how A tuna=621 It u my responsibility M early the Occupml of d¢
requireclpilarwissua=e oraCcrtifwakofOm . Signature of Applicant Date
iwhkIt ' i �ry�9�� All roof coverings to be Class "B" or better
Owner ora Nome qmt Oa
Community Development
SCITYOF '
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408) 777-3333
OCUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
�DICe T Wtwo S C`3�j�s0?OQ
OWNER'S NAME: 1 g p PHONE #
GENERAL CONTRACTOR: 7 Z wi FAX # so &N- 8 y
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
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
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
10/28/03
CITY OF CUPERTINO
WATER HEATER
CUPEf"TIN0 PERMIT APPLICATION FORM
APN# 3,2� D ' /� Dat / 7/D
Building Address: �D I `f
Owner's Name: - Pho �d
Contractor: Phone:p License �/ / C31/
HoT WATER. INC. (}��S�sG/C��� / 40 6 d-
Contact: 963 INDUSTRIAL Q1 Cupe usi ess License#:
SAN CARLOS, CAUFORN14 1)-4. Phone:
Building Permit Info: `/
Bldg ❑ Elect ❑ Plumb L!Y Mech ❑
Job Description:
Residential V Commercial ❑
Cost of Project: fyo-b
• Strapped 11 Op Platform L1 Bonded El
New Location fg/ Replacement
El
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