05040145 CITY OF CUPERTINO tr
BUILDING DIVISION PERMIT n +��J�T.It -- `IINFIORMATI,
Yx�"a`�;.yi.4 w iY1 --.,:4�°'bt.h✓.r'$.� at«+'�`al ` acS 'f al
BUILDINGADDRESS: HOT WATER INC PERMIT N0.05040145
OWNER'S NAME: PERMITMUEDATE
RIE: SANITARY 0 OL NO.
ARCHITECT/ENOINEEN: ' BUILDING PERMRINFO
BLDG ELCCf PLUMB MECH
p 0 0
�ICij LICENSED CONTRACTOR'S DECLARATION
tr1� 1 thereby affirm that I we licensed under prokion of Chapter 9(commencing Job Description
with Secllon 70(NI)of Dlvlit 3o the Budneu and Professions Coddle.and my license if
'S�a in full forc"m ,real. - /�'— REPLACE WATER HEATER
ii Lima.CI Lic.N
Dem Conlrmin,
CHIIECI'S DECLA sfAnON
n
I un mend my piens tall he used as public rcenNs
Licensed Pnlfamonel
OWNER-BUILDER DECLARATION
<f I hereby afOm on 11. ,Business
from the GonlraclCo e:Any C Lew far the
ratcluse
p o following mown.Permit
1710 Ls,Budneu and nue,de ons Code:Any city or manly
1 lei which sayulrca s gems t re c�resaILthe
1,alma rat f r such
h pscoull1 fie a alr my MWment
fr pdann it,issuance,p r also to ma lavision of for wmh parmll to Bb se Law(Chapter
a< (halals Eng Wait pursuant In the of Division
the Buutors License Law(Capmr9 Sq.Ft. Floor Area ValU8t10
(commencing exempt
pthherefr 701D1 the
Dall.f r the le Budwswder professions v1Cnde)of
that io is campy therefrom and the bub it be alleged dur exemption.Any it penalty
of
net ore than by any applicant eddoll..($permit objects the Applicant to a evil pemllY n( 3 g�NV1JffI r 0 0 Occupancy Type
net more than Ow hundred intim(SSW).
1,uownero(tMpmpmy,ormyemplo wiNwtesutheirmlecompenudon,
will do du work,and the muctum is notinmMed oro0ered forwile(Sm.7044,Business Required Inspections
and Finland...Code:The Coal woores License Law does net apply m e ns an owner of q p
property who build,or I m pmvrs tarwn,an d who daeuuch wmk himwi f or through his
awn employers.provided Nal such Improvements art not Intended moRered for wile.If.
however,the buildingor Improvement is mid within one yew of complains,the owner.
builder will haus the burden of paving that a did ant build or Improve for purpose of
sato.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
mossael ale project(Sec.7044.Business and profesdou Cade:)The Contrscmrl Ll.
came Law docs not apply to an owner of property who builds at improves Import.and,
who contract,for such projects with a contractor(s)licensed pursuant to the Contractor's
Licenw taw.
❑I em exempt under See .B A,P C for Ibis Mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Faulty of perjury oro of the following declarations:
1 have and will mdnuln a Carillons of Consent to self-iosum for Worker's Camper
13711,'MoftheU�rC�,forftperfoma=offt�("whichNisKmitisi�.
u rovided for by Secllon 3709 of the labor Code,for the perfmmsna of la
k f Mch Nb pennll is issued.
hew will maintain Worker's Compensation Insurance,u required by Section
itisIssued.
Worker'sCn�Penutlon Inwnntt carrier end Policy numbe�r�art�:5�er: a'TN(a.�l.(.Il� POIky Na.: .7�(l
CERTIFICATE OF EKEMPTION FROM WO RK Is '
COMPENSATION INSURANCE
(This maim need net becample ed Eine pcfmli is fmoe,hundreda,Rws($100)
,it less.)
1 sally that In the performance of the work for which this Permit is lured,l wall not
employ Any Person.try Anncrwa t become subject o to Worken'Compensation
Laws of Calif
App am'
NOTICE
T
NTO APPLICANT;If,Ruer thokinii this Cenifinm of Exemption,you should
become subject to the Worker's Compensation previous of the labor Code,you must
O forthwith comply with such provisions m this permit shall he deemed revoked.
tiCONSTRUCTION LENDING AGENCY
H I hereby affirm that dome,h a construction lending Agency for Pedmmema of
C;, am work for which this permit is Issned(Sec.3097,Civ.C.)
W Q lenders Name
z lender,Address
U Q 1 eedify that I aro said this application and mse that the above Information Is
I7.Fr correct.l agree to comply with dl city rod county ordinances and sum law rclwing in
DU building conseellon,wid aaby,Msodu mpresenmiws of this city to enter upon the
W
have monitored properly for inspection purlmws.
6r (We)agree to sew,indemnify and keep h unieu the City of Cupertino agaWt
.v IIab1110es,judgmcnss,cava and expense.which may in my way acerae against wild City
In U
APPLICANT DS A
eUN Uof do,NDERSof TANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of APPIieuVCoDau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant Camp or future building occupant were or handle Health
material
ss Oe.sed io the 32(4)?nn Municipal Code,ChAPmr 9.@,and la Ncelth and Safely
code.section lss72(a)7 / All roofs shall be inspected prior to any roofing material being installed.
prey
WIII the Applicant or future building upent use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
II huardnus a armaminmu u defi y the Bay Anci Mr Quahly Mwagemant all new materials for inspection.
El Yes
Thaw mAd du auknw mucridsreyuimnunt,undcrCapmr 6.93of Ne CAllfor- D�
tie Health k Satwy Co dc,Seceou1sA15.35533 uu13s534.1 un@,scene uellfdu(wilding
dura ml amenity have a mnwt,that II b my resporulhlllly,to ond(y ale rccupmt of ere
rcyul u ichmelpdorinlsmmcenfaCcniOc Ofacy(tm Signature ofApplica t Date
Ownwmwt `red.net /1/ Dale All roof coverings to be Class "B"or better
Community Development
10300 Tota Avenue
Cupertino CA 95014
Telephone(408) 777-3228
acloF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT # os
OWNER'S NAME: Q I PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following 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 f W C_
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
n
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
# CUOF
PEkTINO PERMIT APPLICATION FORM _
APN# r' ^ ' / _ � / Date:
Building Address: l(J l I [
a s6-yh Dr .
Owner's Name: Phone# _ p]
Contractor: Phone: -�� ��9 License#: / (J��
HOT WATER"-4iNnli TRW , INC. (f/
Contact: SAN CARLOS, CALIFORNIA 6467cPhone: Cupertino Business License#:
r
Building Permit Info:
Bldg ❑. _ - Elect ❑ . _ Plumb Mech ❑
Joh escri tion:
- Resid ntial ❑ Commercial
Cost of Project:
A Strapped On Platform- El Bond .. -
❑ -- -
New Location Re lac ement - -
-- - - - Qty. if ----- -'Applicable Fee IDFee Descri tion Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERM=E Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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