04110085 CITY OF CUPERTIN.O. . < O**N' T+Ra ACT<OaRw z"r,- w ' wRM�BUILDING DIVISION PERMIT-, 2JON:
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BUILDING ADDRESS: . -- -ALL "VALLEY PLUMBING_._--- - - PERMITN"b4110085 ,
10039 OAKLEAF
OWNER'S NAME:. PERMIT ISSUE DATE
PATTY NG 170 BRANNON D 4'
f _ - - SANITARY NO. --'"'" CONTROL N0:
ONE: _.__,.. - .. _. .,. ..�. __ ,- . _ .
(510) 376-4816
ARCHITECT/ENGINEER: - `- BUILDING PERMIT INFO
BLDG - ELEC7_ .,_PLUMB MECH... .
o 0
iso p LICENSED CONTRACTOR'S DECLARATION - --'_ "-- - _
- l hereby affirm Net l am licensed Mer pmvumns of Chapin 9(commencing - - __
=Job DCSCription
will Scc ion]OIMI)of Diveseon3oflW Bu imasaM Pmfcuionx Codc antl mylicense is
rentor a Metre - WATER HEATER REPLACEMENT -
-
qW 1 LAR ION
1. 1 LndcrssanJ clic shall M as records
iG t; Licensed Professmna !/
-ys
OWNER-BUILDERexemptDEthe Commences
<� ON
1 haraso .(Sinn on I em exempt tem dm Conlrato Co e:Any c Law for the 0 _.
-O O following moon.(Section]onstr,Business and Improve,
de ioe Cade:Any oily Of manly /
$� which requires a permit m mnarNCe epee Impmw,demolish.at repair any structure .. .- .,,-...,..�..” .-. ...._ . ._ -- ---�-- �--.,`- � 0 0"
H y prior to its issuance,also requires the applicantfor such permit to file a signed statement .. —__. -
< that he is licensed p.matem m the pmviai...of the Contract.,.License Law(Chapter 9 Sq.Ft. FloorArea -- - , ,-Valuation
E $ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
Net he is exempt therefrom and the basis for dm alleged eureption.Any violation of
Section 7031.5 by a"appiment for a Permit subjects the applicant to a civil Mostly or Occupancy Type
not an=Nan live hundred dollars(SSW).
- pl,lsownwofthepmpenywmyemploycuwithwagesufte wlecompensadon, _
will do the work:and attainment.Istnimm�ded or offend formic(Sec. 1114,Business -_Re aired Inspections
and Professors Code:Th.C.Ow cmr'a License Law doe or apply to an owns of .n '`t`e-w+:,' 9,
propeny who Wlldso firp erns Nercon,and who doessuch workhimulfor through his
ownemployee,provided thaesueh imprevemenu annoy intended reoffered formic.If,
however.the building or improvement is sold within one year ofcompletion,Neowner- .�.__...,....___._ .,..._-.._..
builder will have dee burden of proving Chat he did not Wild dr improve for ptarmic or
ole.).
❑1.as owner of the progeny,am exclusively contracting with licensed contractors to .. . .
construct dm project(Sec.7044,Business and Proresions Cade:)Tim Conmerat s Li-
cerus law does not apply to an owner of property who Wilds or improves dmnon,and
who concocts for such projects with a contractor(s)licensed pursuant to the ConlrutorS .,..-_..,,.._,�.. _ ... ".._.. - -
License Law.
❑I mo exempt under See. ,B&P C for this mason
Owner Dem
737MWORKER'S COMPENSATIONDECLARATION
I hereby sale under penalty of perjury an or the following dem antions:
I have and will maintain a Cen Beam of Conant to self-ieute for Worker's Compen-
Wr
ne,u provided for by Section 3700 of the Labor Code,for the pef(oeence of the
rk for which this permit is issued.
1 have and will maintain W.AeYs Compensation Insmauee;as required by Section
i - — -
of the laCo ole,for t e performance of the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number am:
rries Polity No.: _
CERTIFICATE OFEKEMPTI FROM WORKERS'
COMPENSATION�ANCE
(This section need nut he completedif e u is for one hundred dollars(S 100)
lir mos.)
I cenifv that in the performance of the work for which this permit Is issued,l shall not -
employ any person in any no nnersn as b become subject in the Worlecrs'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Conificem of Exemption,you should
become subject In the Worker's Compensation previsions of the Labor Code,you must �,..
Z forthwith comply with such provisions or this permil shall W deemed invoked.
Z Q CONSTRUCTION LENDING AGENCY
[r 1 hereby affirm that Nen is a construction lending agency for the Performance of
f,Yt the work for which this permit is inmd(Sec.3097,Civ.C.)
W�Q Lender's None
a z Leader's Address
V Q I cenify that I have mad this application and slate that the move in(neatiun is
W E' correct.I agree to comply with all city and county ondinanecs and sum laws relating to
Q V building construction,and hereby authorize representatives of this city to cmerupon the
�fA ab.vnmomio and property for lepection purposes.
(We)agree to raw.indemnify and loop harmless the City of Cupertino against j
liabilities,judgments.cosh and expenses which may in any way accroc against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDSASUlaWS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SQURC ULATIONS.
Re-roofs
Snoun a(ApplicanUContrutor em
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will that applicant or future building occupant store or handle hasudous material
ss ticfined by the Cupertino Municipal Codc,Chapter 9.11,end the Health and Safety
Coca 255320t)?)?
Elyes All roofs shall be inspected prior to any roofing material being
Will the applicant or future building Occupant use equipmel or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil maudnm air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes P.
I have mad the Wmrdousmamrods nquircments under Chapmr6.95 of thc Califor-
niaHcalth&Safcry Cadc,lccd.ns 25505,15533.d25534.1.n&.rs thuifth.building
docs not chem (saw e y responsibility to notify the Occupant of the
requiremc alWmelpsiortoiss cc faCcmficalco(Gcd/vpanty Signature of Applicant Date
04
Owncr or autharfaed agent D—IAll roof coverings to be Class"B"or better . ..
CITY OF CUPERTINO
WATER HEATER aCITYl
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date:
32 — ( —OSS A IStw
Building Address:
100-3e7 A k Lea/ LAL'e
Owner' ame: Ph ne#:
7T ) Aj
Contractor: Phone: License#:
(E / - - d36 a
Contact: Phone: Cupertino Business License#:
A ,q�j 6rtsio -(1961-90c,
Building, ermit Info:
Bldg ❑ Elect ❑ PlumbW Mech ❑
Job Descriptioq:
GW Z
Residential Commercr ❑
Cost of Pr sect: tip
700
• Strapped ❑ On orm Li Bonded rl
New Location ❑ Replacement
X'ppri
Lica\le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING
2 `7 .7
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