03120051 ' CITY OF CUPERTINO
BUILDING N � R�,N,FOOMIO,N
DIVISION PERNIIT COMO , T ;
BUILDING ADDRESS: WATER HEATERS ONLY PERMTTNo03120051
OWNEV NAME: PERMIT ISSUE DATE
LENE B
ONE: SANITARY OL NO.
ARCHITECDENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
pp 0 0 0 0
W Zp LICENSED CONTRACTOR'S DECLARATION Job Descrio8Dt1N�L "
MU 1 hereby affirm that under al I em licensed provisions M Cnepor 9(commencing lr�
,a� with Section 70110)of Division 3 ofthe Bud.mud Pofnssions Code,end my licca=is
;� in roll fora and ef(xt�� REIPLACE WATER HEATER
� LieenscC s.1 JAN 1 3.2004
Con
ARCHITECTS D s
�i 1 urtdcrnanJ my Plem shall M used a public mrnrda BUILDING
3 Licensed prof..i...I '
3� Oat I am exempt
from
DECLARATION
.�0I 1 memereby effindSout on 1 1. oBusin tram d i Cominer Ce is Any c Lew for the
S
00 which ox dawn.(Smear IIB 1.5,Business and a.,derons Code:Any city or county
a�$ which tits Wu a Permit c,,Bum.bwI m4 ppli improv,demolish,or rtpalr my suucwre
Fzy pdormits issuamc,a4u rtquirm the applieaof for sochpeter'sLiecomLaWstadment
< s"theIslicensedpursuantinthepmvidouaftheContrwuu'gLJansenew(Cneprer9 Sq.Ft. Floor Area - Valua[io
$ (eommencingwithkction7")of Diviaion3ef Oc Busineumd Purminu CM)or
Nn he is exempt dtemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant m a civil Penally of 3 Agro 0 Occupancy Type
not mom Nan five hundred dollar(SSW).
❑I.u owner of the pmpeny,or my employees with wge3u Their wle mmpenution,
will do thework,end Neswnmeis not intended or offered forsale(See.7044,Business Required Inspections
and Profusions Cads,The Contucurs Liana Law does not apply u e an owner of q P
property who builds or i m prow thereon,and who does such work himul f orthrough his
awn employee,provided Nn such improvements are not intended motioned foredo.IL
however,the building or improvement is mid within ane year of compiedon,the owner
builder will new dm burden of proving Nat he did rot build or improve for purpose of
axle,).
❑I,as owner of the property,em exclusively contracting wish licensed convectors to
construct she project(Sec 7004,Business and Pofesdans Code:)The Convwur's W.
cause law does not apply In an owner of property who builds or improv desmon,and,
who contracts for such pmjecu with a camreeurDa)licensed pursuant w she Conuaclofs
License law. -
0Iameaempsundm5u .BAPCforlhismosm.
Owner Date
WORKER'S COMPENSATION DECLARATION
1 beneby afine under Penalty of perjury one of the following declmniom:
7037�'W
I hew and will maintain a CeNfeweofConsent uselM1luumfmWorker's Compen-
ion,as provided for by Section 37W of the Leber Code,per de performance of she
rk for which this permit is ismad.
I haw cad will malntem Wrolue.Compensation luurwa,as required by SeNan
of the Labor Code.fm the performance of the work fm which this perba t u issuedy Workefe Compensation Insurance carrier cad Policy number tie:
rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mob section decd not Mcompleod If the permit is formac hundred dollars($1 W)
or pus.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ anyperwn in my manner an a be become subject to the Waftier Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption.you should
became subject in the Worker's Compensation provisions of the labor Code,you must
0 O foMwish comply with web provisions or this permit shall be deemed mvoked.
ZCONSTRUCTION LENDING AGENCY
y
F. 1 hereby efface Na there I..coruuucenn lending agedey for the performed.of
R:> the work for which this permit u issued(Sm.3097,Ci,C.)
W�Q Lendeh Nem.
z Lmtder's Addrea
U C 1 certify that I have mad this application and sure that the shave information is
IL H correct.I agree to comply with all city and county ordinances and slide laws relating to
0U building construction,and hereby mobodee representative of tbaeisy m enter upon the
W above-mentioned pmPeny for inspection purposes.
C (Ws,)agree to saw,indemnify and keep harmless the City of Cupcnino against
y liabilities.judgments,cuts and expenses which may in my wayaecwc against mid City
U z in consequence of the granting of this permit.
APPLICANT UND RSTANDS AND�LL CO�M 'Y WIT�H ALL NO�f/t'POINT Issued by: Date
SOURCE REGU ONS AND LL
Re-roofs
Signamm olOApplicartiContractor I Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding=open,dots or handle ha'radous material
as defined by de Cupertino Municipal Code.Chapter 9.11 and the Health and Safety
Code.Scedo.2553241? �./ All roofs shall be inspected prior to any roofing material being installed.
❑Yes taloa
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 haurdous air conmo itimu,as dcfncd by the Bay Area Air Quality Management all new materials for inspection.
Dixtrict?
UYes �dr�
1 have mw1 the hmardsws materials requirements under Chapter 6.95 of the Csifar-
nie Huith&Safetsections 25
,sections and 25534.1 undcnlaM that Base building
dots trot currently have a tenant,Wt it is my responsibility In notify lie Occup t o the
reyuimmcnta wine must W me s prior oma of cni0cau of Occupm Signature of Applicant Date
9 d3
owns
Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
WATER ]HEATER 0312
CUPEkTINO PERMIT APPLICATION FORM
• APN# /f Z / O Date: j
j6 b b �3
Building Address:
-271-11 Oct bvC L+-
Owner's Nan l Phone#:
xr �- 1 30 9
Contractor: License#: 3 -7 4/S 73
Contact: Phone#:
Applicant/Cea4netar:
1'J (S/o> 5 y /23 -.L-
Building
Building Permit Info:
Bldg Elect lumb Mech
Job Description:
esidential• BUJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: 6
6 00
rypef Construction: Occupancy Group:
L
Qty. if
Applicable Fee ID Fee Description Fee Group
I BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbin Permit Issuance PLUMBING
BPERMFEE Bld Permit Fees BUILIDNG
BMITIGAT Housin Miti ation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG