03080142 f C1TY OF CUPERTINO > ... is�vm''a'f
BUILDING DIVISION PERMIT SCO TRATORINFO�RMA TION
OUILDING ADDRESS: HOT WATER INC PERMIT NO.03080142
a
OWNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
ANNA RTT
I'D
NE: (650) 298-8494 SANITARY NO. CO1f 04 10.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION
4 u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 700KBof Division Sar NC Bainessa9d Professions Cade.and my license is C
a in full�i and fie � p �i
i'qz LlaensCClesf I IC 36lZ REPLACE WATER HEA 6
Dare Cunt or n 67 P
eF-F A CHI ECrS TION SEP 2 9 2003
C C< 1 d tlemtand my plain shall Mused as public rccard,
ear
7e0 Licensed Profession.] OWNER"BUILDER DECLARATION BUILDING
2 i Z 1 hereby allow Not 1 em esempt tram to Can.,,I',License Law far the
00 following...a.(seed 91131.5.Business and Pmfcssina Codc:Any City or county
5$� which requires a permit to construct,alter,impmw,demolish,our repair any atmetum
-ZIn poor In its issuance,also requires the applicantfor much Permit to file a signed statement
a 0 that he is licensed pursuant to the provisions of NeCanwctor'sLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
2 (commencing with Section 700B of Division 3 of the Business and Professions Code)or
i that he is esempt therefrom and the basis(or the alleged exemption.Any vitiation of
Semon lints by any applicant for a Permit subjects the applicant to a civil Mostly of APN Number Occupancy Type
not more Nan five hundred dollars(350B).
Las oworaf ante propeuclum is omntende oro wqa uNehaole campewttess
willdothdwmk,and the suaC Contractors
Lt did draw doesed no,apply an am owner of 502 - FINAL 1e0W"LNRC"FRGY
and Professions Code:The Cont emon,License Law dins opt apply lf an owner of
own enywyers,pdforimprat suchertomandwha ddoes amn suchwmk himselfor Ma 506 - GAS TES
howemployes,prog or Improvement
mch;mpmwm within am
not ear of completion,
for we,B, 507 — FINAL PLUMBING
however,the have
the
b r improvement is that
he i iin not
year of completion,to owner-
builder will have Ne burden of proving Net he tlItl not Wild or improve for purpose of
reale.). -
❑1,as owner of Ne property,am asclofively contracting wit licensed convectors to - —
construct the pmject(Sec.70",Business and Professions Cade:)The Conlracmz's Lt. ,
scene Law does not apply in an owner of progeny who Wilds of impmvcs themon,and
who contracts for such projects with a contranor(s)licensed pursuant to be Contnnoes
License Law.
❑l am exempt under Sec. ,B R P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby e(fmm under penalty of perjury,arc of Ibe following declantiom:
1 hew and will maintain•Certificate of Comdnuo self-rime,for Workers Compcm
sstion;as provided far by Section 37W of tM 1aWr Code,for lie pertasmancd of the
work for which this permtt is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
00 of the labor Code,for he performance of the work far which this permh is Issued,
My Worker' Compensation Inst, ac canu
,icraftI Policy n �j p/
mer._�t I't'�� Ia/i✓0 f/PoIicY No.: l s e3UX3
CERTIFICATE OF EXEMPTION FROM WORKERS
J.
COMPENSATION INSURANCE
(Ihlsscetion wed notMcompletedirthe parmilisforomhundreddoltim IBD)
or ass.)
I ceniry that in the Performance of the work four which this Permit is issued,I shall not -
employ any person in any manner an as to become Subjecua the Workeri Compensatlan -
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificaa of Exemption,you should
become subject to the Workch Compensation previsions of IN,IaW Code.you must
�Q forthwith comply with such provisions ear this Permit be learned revoked.
ti� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is comuuction lending agency for the performance of
Y, .>-t Ne work fur which Ibis permit Is issued(Sce.3D90,Civ,Cd -
A Iander's Name
Lender's Address
;)Q 1 anify has I have reed Nis application and sum that the aWw information is
y U Wilding 1 once to comply with all city and county ptati mor and cute laws relating e
7V above gconswdpatiend hereby infraction
nfauNanmmpscxnuniwsof this city to enter upon Nd
L. ahovm(We)a agree
progeny for emnify an keep ha.
(We)agree a,taw,Indemnify and hi keep hay in an the City of Cupcnst s id City
L.tiZ Ilaemourt eareofnhe costsandof this pernit, may in any way eccmc against said
J z in confequcncc of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE R�r.61Jtj4T7\ s � /
2 O
Re-roofs
Sig Teo ApplianVComraemf Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uceupanntore of handle hazardous mareoal
U dented by the Cupenino Municipal,Code,Chapter 9.11,and be Health and Safety
caea sddt 25532(.)?Jz(a)7
as C3 No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future Wadingaccepant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
in hmsrdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
R
❑Yes No
1 have read the hazardous materials requirement,under Chapter 6.95 of the Califnry
tie HealNASafety Coda Sdctlons 25NIS.1s57J end 15514.1 undersand that if dm Wilding
does non comenlly haw o tenant.Nat is u my refpomihility to nndly dee meopent ofthc
rcy�u�'tmmcnu�YL;ch�Ibe( lpn��uwmofaCcniricamof t Signature of Applicant Dale
OwrnhomrJagcnl Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER 0 3 `'"y o
CUPERTINO PERMIT APPLICATION FORM
APN # / Date:U sl/a6 03
Building Address: S b 8
hr7,�S1. � � ?
Owner's Name: Ph o e#:
�IJN L/0g -)w
Contractor: Pho e: Li ense#:
NDS w� 2 , gYiy ��361z
Contact: P e: Cupertino Business License #:
elazt 6w , rJ T- zy8 - �Y5
Building Permit Info:
Bldg ❑ Elect Cl Plumb �p Mech ❑
Job Description:
Residential �b Commercial ❑
Cost of Project: S60 2
. Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A lic e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING