03080149 ,"CITY OF CUPERTINO . '- r` '� �'•'.
BUILDING DIVISION PERMIT 4GONT X077 ICAMFOR MAT ION .°
BUILDING ADDRESS: HOT WATER INC PERMIT ND03080149
AA nA17 AAUAJDC�W QT_
OWNER'S NAME: 2531 GRACELAND AVE PERMTTISSUEDATE
NE: SANITARY N0. /26"29CONTROL NO.
(650) 298-8494
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
+ort LICENSED CON(RACI'OR'S DECLARATION
U 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
¢� with
Section](it acDiviaion3of Joe Bmincsand Profcssinnetodc2nd myliccnm is pi's. a LE®
n in lull fomeand BCG ��1/O�t1/5_/1/ r NA
>gz Luen saes» REPLACE WATER HEATER
e`p Da¢ Contractor
ARCHTILCI'S ECLARA ON [
I understand my pleas shall M used as public records SEP 16 2003
h
Licensed Pmfcasiunel
OWNER-BUILDER DECLARATION
iY 1 hereby affirm list I am emntpl from the Comractmes License Law(or the BUILDING
p O following rcamn.(Section 7031.5.Business and Professions Cale:Any city or county
3$ which requires a permil to construct,alter.improve,demoleh.or repair any structure
Poor I.its issuance.also requires the applicant Branch permiuo rile a signed statement
xx that heislicensedpursunnnnthe previsions n ReConlmcer'sLicenselaw(ChaPes9 Sq. Ft. Floor Area Valuation
a (commencing with Section 7")of Division]oflhe Businemand Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Seen..7031.5 by any applicant for a permit subjccu the applies.,to a civil penally at ._APN NUmbCr. _. _ Occupancy Type
not more Nan!hundred dollars($500). - "-- -- -- "- - '---
❑h az owner of the property,or my employees with wages az their"[a compensation,
will do the work,and the structure isnot intended or ofered(or sale(Sec.7W,Business 502 - FINAL �� jAjRG RGY
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselror through his 506 - GAS TES '
own employees,provided that such improvements Are not intended or offered for sale.If. SO7 - FINAL PLUMBING
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose or
salt.).
1,.s owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.701x,Business and Protrusions Code:)The Contractor's Li.
came law does not apply to an owner of property who builds or improves thereon,and, ,
who contracts for such projects with v comnctor(a)licensed pursuant to the Canlnaoh
License La-
0 1 Ann
aw.O1An .A.PL order Seo. .B A P C for this recon
Owns, Date
WORKER'S COMPENSATION DECLARATION
1 hereby Arrive underpenally of perjury one of the following declarations: _
I haw:and will maintain a Certificate of Consent to self-imure for Worker'sCompsn-
lion,az proviJCJ for by Section 3]00 of the labor Code.for the performance of the
work for which this permit is issued.
P71:Fpa oil will maintain Worker's Compensation Insurance,As required by Section
J l.re,
of @e Labor Code,for No performance of the work for which this Permit is 1ssuAd. .
My Worker's ,Upon/,51alio�,+Insumnaarriier and Policy nu Aare:
Cartier. - I ,r Ih. U"'�' Policy N,.: I lis�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed 1(the Permit is formic hundred dollars(SIM)
or less.)
I certify Out in the perrmmanee of the work for which Nis permit is mace.l shell nut
employ any person in any manners,az e become subjecOo the Workers'Compemallon
Laws or Caliranow Dare
Applicant
NOTICE TO APPLICANT:If.After making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you mus
z foMwtth comply with such provisions or this PCrmil shall Fe deemed mvoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby salon that Ncre is a consu actin lending agency for the Performance of
Y> the work for which this permit is issued(Sec.3097.Ci,C.)
Q Lender's Name
z Lender's Address
;)O 1 cunify that I have mad thisaMidiniie.and enc that the.bove information is
,L (r-' comi I agree to comply with all city and county oNinanco and state laws relating to
DU building construction.and hereby authonm mpracmatives of this city to enter upon the
h above mentioned property for inspection purposes
y (we)agree to save,indemnify and kap harmless the City of Cupertino against
N
liabilities,judgments,costs and expenses which may to any way accrue against mid City
J 7 in consequence of the granting of this permit.
r-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date iL�j. —Cl
SOURCE REGULATIONS_ \ - , e &u/03 Re-roofs
Signature of Aa
pli��n✓ConnlnetorflM 'Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or floum building occupant stone or handle havudous material
As defined by the Cupertino Municipal Code.Chapter 9.17,and the Hcallh and Safety
Cade.Section 25537(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yoe ❑Nu
Wits the apPTicmtmr muse Wilding occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
:it I..odnus air cantsminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
' ❑Yes ON. '
i have read the haaNuus maerialimyvimmenu under ChaPrer 6.95 of the Califor-
niaFI"I"SafetyCode.S mn5f15.25533"n5W.lunJersmndthuiflM Wilding
does not currently hoe a¢rant that it is my responsibility m artery the pant or Bic
requiremcnl melVa iuusneamfaccn;0cammlS7c�Zmcy4r Signature of Applicant Date
Owner or aumulfved seem `.'F/`O VD,e All roof coverings to be Class "B"or better
a
CITY OF CUPERTINO .
WATER HEATER o 3 l
CUPERTINO PERMIT APPLICATION FORM
APN # O Date:
Building Address:
� 73f3 O 1-t, n�ti . ot,a Lr•
Owner's Name: �- Phon
I� IZIL S v. � 68) 25�- 333b'
Contractor: hon . License.#
Contact: Phon : Cupertino Business License#:
Cl �2ts Gvs ����
Building Permit Info: '
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: Oj
�O d
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement(�
Qty. if
Applicabk Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING