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04100189CITY OF CUPERTINO "+'^�_{ '�' "•'" ` -""R " : - BUILDING oIVIs1oN ' : PERMIT CONTRACT01;t11�Vk(3�2�M+ITTON 1 , . „ ,.. BUILDING ADDRESS: n141 PT,TTM TUPL2 IN - WATER HEATERS ONLY PERMIT NO. 04100189 OW NER'S NAME: PERMIT ISSUE OATS ONE: SANITARY OL NO. ARCHITECT/PNCINEER: BUILDING PERMIT INFO - - BLDG ELECT PLUMB MECH • o 0 0 0 LICENSED CON'TRACTOR'S DECLARATION Job Description ' I hereby arfrm Net I em licensed under provisions of Chapter 9 (commencing ... ... ...- withSmuonTOfU)a(Diviron Jof the Businea and Pnlcssiom,lic.rcis inrenlfsaremerr 4 %5my Lk REPLACE WATER HEATER Date Cdnla, ARCHITECTS DECLARATION - IunderstsnJmyPlansatollheusedazCaRmenthe- pu Liccnsed Pm(mmu ud - DECLARATION Oat I am exempt from We Cortrac taw for the 1 hereby Nm' 1 uusin Any . Sem s an Co : C following (Sarno Io L3,Buinessendrns, {inns Code:Anycity or county 1. which requires a Permit re rnmww, demolish, ri mash any stemma for - such Prier will issuance. pursuant a@o rt in the the ePplkent (tie Con Permit w . a signed emmmmnl p that he{alkaliwithsetion700) provisions the Law Sq. FC Floor Area Valua on • - sionsCPmr9 ofLlcBuacesau<nae sionf (come4canwiNSerefrom 7000) Of n3 rftheegodeeand Cab c) orthat on.Anynna he la exempt therefrom and the basis for tie alleged exemption. Any violation of basis 31VIU*0*1700 UccupancyType Section 7031.5 by any applicant, for . permit subjects the applicant macivil Penalty of not mom than five hundred dollars (5500). ❑ I, a Owner of the property, or my employers with wages an their sale compensation,. Required Inspections - will do the work, and the structure is not intended or Offered fauak(Sec. TOM, Business and Professions Code: The Connacwra Li«nae Law duan not apply to an Owner of - pmMnywMWildanrimpmveathmeon,andwhodoessuchwurkhi.vf.rthmughhis �- ,. .. - own employees, provided that such improvements are notimended oroRered fersate If, however, the building or improvement is told within oil Sear o(compktlon, Ne owner builder will have the burden of proving that he did not dual or improve for purpose of sale.). ❑.1, as mune, of the property, am exclusively contracting with licensed cenuecmrs to construct the project (Sec. TOM, Business and Prnfesslons Code:) The Contractors Lb CCNn law does not apply in an owner of property who Indian or Impmwa dlemon, and. _.. - r.--. - - ... - -.- .... •--��... "• -- " " .�+�� who conlmCB for such pmjecB with aconneelor(s) licensed pursuant to the L•nnnacon's -.,�� Llcense Law. El I am exempt under Ste .B A PC fm On. reason Owner Data - WORKER'S COMPENSATIONDECLARATION I hereby affw under penally of perjury One of the following dedfordonse ❑ I have and will maintain a Ccoditum Of Consent to aelr-insure for Workers Compere - .alio., as provided for by Sccuon 37M of Ne labor Code. Tar the performance Of the .,it for which this permit is issued. have and will maintain Workers Compensation Insurance. as mquirtd by section OOof Ne Labor Code, for the perowence ofth. work far which this Permit is issued, - My Workers Compensation Insurance earim and Policy number am: Cartier. 5 r I-- Polley No.: b0007 - CERTIFICATEOF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE (This acction need nmhemarad ed true permit Is Inform hundred dollars(SIM) lir ImO.) I certify Not in the Performance Of the work for which this Permit is issued. I shall not employ any person in any maMcrsa u in become subject to thewarkers' Compensation Laws of California. Dam ,- Applicant- - — NOTICE TO APPLICANT: If, after making Nis Certificate or Exemption, you should became subject to the Worker's Compensation provisions Of the Labor Code, you most forthwith comply with such provisions Or this permit shall ed domed revoked. CONSTRUCTION LENDING AGENCY I hmmhy affirm that thea ie a Convection lending agency lot the, Imfowamm or the work for which this pewit Is issued (Sm. 3097, Civ. C.) Lender's Name Lenders Address 1 certify that l have reed this application and nate that the above infmmatiun is correct. I agree to comply with all city and county ofdinarms and state laws relating to building com ueioi, and hereby ambodae repmsentauves of this city to enter upon the - ahow-rocationed pmPeny for inspection Pumoaea. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expense: which may in any my acme against said City in consequence of the Of this r) Standing pewit. APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date !// SOURfj!ONS. trAIt�\ Re-roofs ilii 5igna5 ppGcanuco Dale H OOS MATERIALS DISCLOSURE RDOU Type of Roof Will the applicant or (Musa building occupant Tom Or handleallousmaterial az darned by the Cupertino Municipal Code. chapter 9.12, and the Health and Surety Couc. Section 25532(.)? All roofs shall be inspected prior to an roofing material being installed.❑Yea -" 4th — If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant use cquipmanl or devices which emit moudour air cmmeminmtts ve defined by the Bay Area Air Quality Management all new materials for inspection. Dildet? ❑Yes Qyu- 1 have read the ha>abrmi meedals mquimmen4 under Chap¢r6.95 arlhe Callur- niaHcalNASafctyCodc.Sccuom25MS.25533md2553a.lundcnwvbdmtifthe building does nor curend, how a tenant, Net it is my map ruchiliq m noufy the a:cu d of requimntoadsawl mus ctpriorwisy ceofa Crnifeamor Oce m , � , Signature of Applicant Date � All roof coverings to be Class "B" or better Owner tar audtorived agent Data aClOF UPEI�TINO Buil Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 artment JOB ADDRESS:PERMIT !Q til L -a -- I 0 941 D v 1$ 5 OWNER'S NAME: nr : w PHONE # 2.5 2. -N9 23 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 01,;2° ignature Date Please check anvlicable subcontractors and complete the followine information: Owner/ Co4ractor Signature (4 24,ip Date 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 Owner/ Co4ractor Signature (4 24,ip Date 4 CUPEI,TINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM /' APN # 3 i 3 v 2-6 (/� Date: y Building Address: � (.-. tl� ate_ Owner's Name:� - q crn°-o Phone #: Contractor:_IlO 214 License #: 3 SlS 73 Contact: �-�-' Phone #• 800 Applicant/Cea4aetor: ,� • - YJ • � - � �S/ o> 5 /23 2 -- Building Building Permit Info: Bldg Elect lumb Mech Job Description: esidential ,Lr% Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: Valuation: Type of Construction: Occupancy Group: Qty. if ADolicable FPr m vee n - BENERGY Ener 1 BUILDING IN BPWHEATER Water Heater / Vent BUILDING / PPERMITFEE Plumbing Permit Issuance PLUMBING BPERMFEE Bldg Permit Fees BUILIDNG BMITIGAT Housing Mitigation Fee BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG Ap z7 5`?'6 � V. � �