05040184 CITY OF CUPERTINO c :7*1 rorr«?.+, F�'�' " +> f ' �
BUILDING DIVISION PERMIT CON'LR°[iC"�TF'O
URINRMATIQN
BUILDING ADDRESS: PERMIT NO.
WATER HEATERS ONLY 05040184
iHER'S NAME: PERMUISSUEDATE
NE: SAN IARY 0. OL NO.
CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
]
LOO LICENSED CONTRACTOR'S DECLARATION
1 hereby af0mr that 1 am licensed under pro,tam.of Chapter 9(onmnmming lob Description
with Section 7000)of Division 3 ofthc Business and ProfeWons Code.and my license is
LlcenfullI.se CWlde�. Lia L
9 Delo .S _ W TIN •REPLACE WATER HEATER' FINALE®
I understand my plans Mall W used u public mcmdas
DIU
it Licensed Pmressional ^ " 112- 2005
OWNER-BUILDER DECLARATION
si i I 1 herehy Mm that 1 em aumpt from the Canuacm's Liccrom law for the
O o following moon.(Section 703 1.5,Business and Professions Code:Any city or county
S$ which requirss a permit to csmuruct,alter.Wprom,demoindt or repair any structure
y poor to its issuance.alm require the applicant for such permit m foe uigmd rutentern
< that he isll¢mdpursuant in the provisions ofthe ContracturLicense law(Chapmr9 Sq.Ft. Floor Area
UILDING
�tFC (commencing with Section 700(y)of Division 3 of the Business and professions Code)or
3$ that M is aaampt muefrom and the bu4 for the alleged eaemplioe,My violation of
Section 7031.5 by my applicant for a permit subject.the applicant to•c oil penalty of 3 4 3pe10 0 Occupancy Type
not mom Nm Bro hundred dollen(5500).
❑1,u owmr of the pmpmy,car my mploy withwage a tie mic mmpemilm,
will do the work.Wd the Wtrupmre la notimeded oroffered foraale(Sec.7044,Bosoneu Required Inspections
and Piefmmns Coda:The Conuxmr License law does Out apply m e ns an owner of q P
property who builds tar improves thereon,and who does ouch weak himsel f m through his
own employes,provided that such Impmwments K not Intended eaoRered forme.If,
however,the building or Improwmem is sold within oro year o(comple oo,the Owner.
builder will have the burden of proving that he did not Wild or Improve for purpose of _
sale.).
❑I,as Owner of the property,am ueluively contracting with licensed comruton m
construct the project(Sec.7044.Business and Pmfeuiom Code:)The Contractor's Li-
cam raw does nal apply an an owns of property he bell&car improves thereon.and
who contracts for such projects with a contractor(s)licensed pursuant to the Comnctots
License raw.
t7 1 am mourn undu Sao. .B&P C for this maano
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury oro of the following declarations:
I ham and will maintain a CenlGeam ofComm m off-iuum for Workouts Centro.
cation.u provided fm by Section 3700 of the labor Code.for the perform once of the
work for which this Permit is broad.
0 1 have and will maintain WOrtrls Compensation Insurance,u required by Section
3700 of the Labor Code,for the Performance of the work for which this permit is Issued.
My Worker Com ural Imranae nmier and Policy nuOther.-
Can,,,
'J-- ' �� Policy No. q
CERTIFICATE OF FXFMPfiON FROM RKERS' '
COMPENSATION INSURANCE
(This sedm need norbecumpleed Ifthe permit Ica forane hundred dollen($100)
or Ica.)
1 certify that in the performance of the work for which this Pencil it issued.I that not
employ any person in my manner ansa m became subject in the.Worken'Campemdon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate:of Exemption,you should
become subject to the Worker Compensation provisions of the Labor Code,you must
07.. forthwith comply with such provisions w this permit Wall he decmcd mocked.
y'O CONSTRUCTION LENDING AGENCY
[•+ l herebyaflim this Nen I..construction[coding agency for the performmec of
6.> the work for which this permit Is issued(Sec.3097,Cih,C.)
W Q (.ender Name
v7 z Lender's Addrm
V O 1 certify that 1 ham read this application and won dau the Wom information is
ry Ecorrect.l ague m comply with all city and county oNWnces and auk laws reladng m
0 C.) building construction.and hereby allthodm reprmmuims of this city to color upon the
W Lyabove-mentioned property for inspection romances., (Wo)acro to taro,indemnify and keep harmlm the City of Cupertino against
�.t rjj IlabiliOea.Judgme eau mdexpe latch may my wy acme agalnauaid City
V APPLI_{{yyA ytdn77 k�I Eau Df A It a ALL NON-POINT Issued by: Date
SOURC.S„fIA��U
`F�ay6 Re-roofs
Signuum of AppImNUContracmr /lo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tion applicant or future Wilding eccupunt store or handle hazardous material
as dented by the Cupertino Municipal Code.Chapter 9.11.and the Hoilth and Safety
7Dbuide.Sadao 255320)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes UN.—
Will tion applicants(umre building=upset mequipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
ct?
it hmardnus air contaminams u defined by the Bay Area Air Quality Management all new materials for Inspection.
OYea l
I hew mW the heraNnus mahouts requirements under Chapter 6.95 of the Califor.
u Health&Safety Code.Stations 25305,25533 and 25534,1 underNod Not if ale Wildingata not cuncntly haw a mnam,that II u my responsibility m malIy IW occupant of the
gwmmy daa�atW` epd maracw[camafoe Signature of Applicant Date
ownermaumarneda mi / Dpm All roof coverings to be Class"B”or better
Community Development
#� 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
":OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: !O/ c n , ��td n . PERMIT # a S 0 g 0 IF
OWNER'S NAME: G-2, �o (� t PHONE # t/zl 4 -/6 z
GENERAL CONTRACT • LL)at&,, Ko_mtA,, FAX #
I am not using any subcontractors: L3 at- �4a]Q... --,:u � �V/0 5
Signature T— Date
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Ask 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/Contractor ignature Date
04/28/2005 22:54 5105383282 LEGALITIES INK PAGE 02
'
CITY OF CUPERTINO Bonita J. Jenklns
WATER HEATER North Bay Permits
SCUPEkTINO PERMIT APPLICATION FORM (510) 541.1232
APN# 2 3 S Date: Flo2
Building Address: /O! el e
Owner's Name*. Phone#:
Contractor: . phone: License#:
Gt/ 8'00 8"315 -59,16 374573
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect CT Plumb Mech ❑
Job Description
Residential zVCommercial ❑
Cost of Project: cin
*ew
rapped On Platform Bonded El
Location ❑ Re lacementx
Qty: if
Applicable : Pee TD Fee Description Fee Grott
BPWHEATER Water Beater/Vent BUILDING
PPERMITFEE Plumbin Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLTC Business License BUILDING