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04090053 ,.,CITY OF CUPERTINO " +� ..0 ' BUILDING DIVISION PEMIT CUNTR�lTURIIV �OR, 1vIAGTON BUILDING ADDRESS: \ PERMIT NO. 80 PARK 17TT.T.A 21, R04090053 OWNER'S NAME: PERMIT ISSUE DAIS E: SANITARY OL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �Op LICENSED CONTRACTOR'S DECLARATION O�'� L rd(� 1 hereby affirm Net 1 am rthe Bu under and Pmoons of Chapter 9(commencing is JOb Description �� with Section by a)of Divislon3 oftoesed Businesseand Professions Code. 9 my[team=is in full forte and effect. LicEDense Class Llh.N REPLACE WATER HEATER ic Dace Contractor SEP 2 unahe ARCHRre Su DECLARATION 004 ?s U 1 dersnd my plans shell m used public rds L G Licensed Professional BUILDING ��� OWNER—BUILDER DECLARATION ON ■)1 �I® �I�� I hammy afRrm Nat I am exempt from toe Contractor's License Low for the y/�U L i D o following mason.(Section 703 1.5,Business and Professions Cade:Any city or county $9 which requlms a permit to construes,eller,imprnve.demolish.or repair any structure F�Ha rn,to its issuanec..Is.echunes toe Applicant for such pcnniUo Ntal e a signedaernut < the M is licensed pursuant to the previsions of thC Comment's License LAw(Chapter 9 Sq.Ft.Floor Area Valuatio m (commencing with Section 7")of Division 3 of the Business and Professions Code)or Nat he u exempt imminent and the beau for the alleged exemption.Any violation of �3,v Section 7031.5 by any applicant for a permit subjects On applicant to a civil penalty of 3wi,#Sn�Mr O O Occupancy Type not more Nan five hundred dollen(5500), t9 Lx` P Y '7P ❑1,As owner of iM property,or my employees with wages as their sole compensation, will On thework.end Nemoctute isnotinendei oroRemd fouale( w,.7044,Business and Profession Code:The Contractors License Law does not apply he an owner of Required Inspections pmpeny w ho bui Ids or improves thereon,and who does such work himsel f or through his own employees,provided Nal such improvements am notimended oroRemd for sale.If. however,On building or improvement is sold within one year of compiedon.the owner. builder will have the burden of proving that he did not build or improve firs parpose of talc.), 1,a owner of the property,am exclusively contracting with licensed cot actux to co nmct the project(Sec.7044,Business and Professions Code)The Contractor's Li. cense law does not apply to an ownu of property who builds or improves themon.and who contracts for such projects with a conhvcwgs)licensed pursuant he the Committers - Licenm Law. ❑tem sae/h9p�'under7Sto � .Bk PCfor thi ma n IQ ORKER'SCOM/9^NSATIONDK RATIO I mmby ef0mm under penally of perjury one of On following declvallans: ❑1 have and will maintain a Certficatt of Consent to self-insure for WmkeraCompcm- ution,u provided for by Section 37M of On labor Code,for the performance of the work for which this Penni,is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 37110 of the Labor Code,for the pulromance of the work for which Nis permit is inner. My Worker's Compensation Insurance canna end Policy number me: Cartier: Polity No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE mus section need not M comp lcted HOW)emit is for ane hundred dollars($1010 nr less) 1 unify that in the performance of Ne work for which this permit is issued,I shall not employ any person in any manneru ss in become subject o the Workers'Compensation Laws of Califerna.Date Applicant NOTICE TO APPLICANT.IL after making this Ccnifwaw of Exemption,you should become subject in the Workers Compensation provisions of the Labor Coda,you must ,Z forthwith comply with such provisions in this remit shall he deemed mwkcd. 'tiz' O CONSTRUCTION LENDING AGENCY (� I hemby affirm that them is a constmcton lending agency lot Nit performance of the weak for which Nis permit is issued(Sec.3097,Ci,C.) W� Q Lender's Name D z Under'a Address J Q 1 certify Net 1 have mad this application and slaw that the above information is W coma 1 agree to comply with all city sed county ordinances and saw laws retailing to C U building construction,and hereby authorize mpruenatives of this city in enter upon the Fn shove-m,judgdproperty st forinspection purposes g� (Wit)agree to use,indemnify sed keep humka the City of Cupertino against wry Ilabilin ofhecastsantl expenses which may in any way scene against said City / y V 7 A APPLICANT of the grueling of This permit t/ r7 APPLIC/EApNE'T (U7ND�ER—STSA/NDS AND WILL COMPLY WITH ALL /N/Oq PO NTT Issued by: Date `OUR.l1 ! 17 N!' /1t�YI 4L� mac!/ ��/ —r Y Re-roofs gnmemof ApplicanUComnc Data HAZARD S MATERIALS DISCLOSURE Type of Roof Will the applicant or future building uceupantmore or handle haardous material as dcrined by the Cupertino Municipal Code.Chapter 9.12,and the Health anti Safety Code,Section 255326n ❑YoNa All roofs shall be inspected nor to an roofing material being installed. If a roof is installed without first obtaining an inspection,I agree to remove Will Ne applicant or future building=upon[use equipment or devices which g Znit hazardous air contaminants a defined by the Bay Arca Air Quality Management all new materials for Inspection. Diauicl7 ❑Yes u I have mail the haardous malermismquimments underChapwr6.95 ofthe e Caldor. -is Heal&Safety Cede,Sections 25505,25533 and 15534.1 undersand thttifthC building does not currently haw a Ansel,that It is my ormonsibRity,w notify flc m:cupeol of the myui swhic must etpnor uuccola CcelfcamofOccu cy. � G!ti /D Signature of Applicant Date O ,,mnedxea seem Dam All roof coverings to be Class"B"or better i CITY OF CUPERTINO , WATER HEATER 4D9G�� 40CUPERTINO PERMIT APPLICATION FORM APN# /C O �� 2 21 ate: ioSi ?'2� Building Address_: G Sbfsb /��i t/ a c Owner's Name.— Phone#: 6� �c0r-r 7- Contractor: Contractor: Phone: License#: Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg [I Elect ❑ Plumb ❑ Mech ❑ Job Description: 74 ( Residential E] Commercial ` � ❑ Cost of Project: Strapped ❑ On Platform L1 Bonded New Location I Replacement ❑ Qty. if AppliII) Fee ID Fee Description Fee Group PWHEATER Water Heater/Vent BUILDING PERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 M1CITY OF Fax(408)777-3333 `UPEf�TINO Building Department JOB ADDRESS: ra r-SW7Z?) PERMIT# Et�ao cl4rl� OWNE46S NAME: f� 'T.J;aPg PHONE # GENERAL CONTRACTOR f �,,► FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: 66 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 • �7�"/: .min�r�r/ I Own tr or Signature Date ' �. � G ..J vy,'.A r ..r -§. l - Y Wi`}`itW- r -..ah.M. Y "LM1. ♦. v a... t Community Development 10300 Torre Avenue Cupertino CA 95014 e^ CITY OF Televh(// (40)777�i3 28 ---0UPERTINO Building Department JOB ADDRESS: ra .-r�,T.P.) PERMIT # E EU O S NAME: ©, PHONE # GENERAL CONTRACTOR.- FAX # 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 ? w Ornamental Sheet Metal Painting/ Wallpaper Paving �. Plastering -Plumbing Roofing Septic Tank " Sheet Metal Sheet Rock Tile -_.,.,Own o tr or Signature Date