05050078CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CUNTRACT , RA, F'bItMATION �s
BUILDING ADDRESS:
RUMPKIN 2-T
SOUTH BAY PLUMBING
PERMIT N%5050078Ogg
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OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY —CbftOL NO.
ARCFm ER/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT MECH
0PLUMB
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LICENSED CONTRACTOR'S DECLARATION
Job Description
rcby afal I licensed under provisions of Chapter 9 (commercial
MRrm Nam
with Section 7000) or Division S of site Business and Profesm a, Code, and Imenmis
rm�a�
maerce ` Lk O
WATER HETER REPLACEMENT �'
NILE®
Dau CanlDECL
ARCHITECTS DECLARATION
1 understand my plans shall be used at public records
V�J 2005
Licensed Profc sionnl
OWNER-asompt frDECLARATION
I hereby (Om law for the
I oro esemnl from Ne Canins,
]RSCS, Business and Professions Cade: AnY city or manly
following moon. , an Co e: Any
permit t
which requires •permit re erre aim,, Impmw, ticm014h, fir repair any &Imment
elm the tiro applicant for such permit m file a signed ststemem
prior k s issuance, Me
Sq. Ft. Floor Area a '
to Ll cram law Chapter 9
That is licensed punuav 7010) provision lir the
l pursuant
p
the Busiren and Chen or
o a Business
exe with Session land of Division 3
on. Any
Nal lie 4 comp] Nem(mm and the hula for d7e alk{ad emmption. Any violation of
(comm Is the
3 OMV010P,10 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not mom than five hundred dollars (5500).'
C 1, as owner cruse property, or my employees with wages u their mlc compensation,
Required Inspections
will do Newark and the sum nam 4 not intended aronered for safe(See, 7044. Busircu
and Prefstsiav Cadc: The Cont acwYs License Law docs not apply in an owrer of
property who builds or improv tbermn, and who doessuch work himself m Nrou{h his
now employes, provided timsuch improvements art rioUnteadad ora@ted rorsale. if.
however. the building or Improvement Is mid within aro year of mmplcoon. the awner-
builder. will haw the burden of poving that be did not build or Improve for purpose of
sale .3.
C 1, as owner of the properly, am "elusively contracting with licensed continuum 7o
construct the project (Sec. 7044, Business and Profession Code:) The Coaoac7oYa U.
rove law does not apply in an owner of property who Wilde or topmost thereon, and,
who contracts for such projects with a conttmucts) licensed puman7 to Ne Comnaots
'
License law.
C I am mallet unser Sec. . B & P C for 444 memos
Owner Data
_
WORKERS COMPENSATION DECLARATION
1 Manby M. made, penalty of perjury aro of Ne following decluWov:
1 new and will msinuln a CeNficata of Consent to sel6ivure for Worker's Cmnpem
-a 'an, u provided fm by Section 3700 of the labor Code, for the performance of tad
work for which this permit Is issued.
❑ I have and will maintain Workers Compensation Insurance, u required by Section
3100 o(Nelabor Code. for Ne performance of Ux work for which this permit 4luued.
My Workers Compensation Insurance carder and Policy num am:
/
Carries�'�'G�1t Cl3rt0 Policy No.: ^OO
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CERTIFIC�F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rTh4 section reed not be completed if the permit 4 furore hundred dollar (SIM)
or less.)
1 reser, Nm in Ne performance of to .ark for which Nis permit 4 issued, l craft rot
employ any person in any manrcrm as to become subject in i m Workers' CompensNan
Lam or Calirmau. Data
Applicant
NOTICE TO APPLICANT: IC after making this Certificate of Esemption, you should
become subject 7o the Worker'& Compensation provisions of Ne lahm Cade, you most
'
raMwith comply with such Provisions or 444 permit Nail be dermad revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem Is construction lending agency for the rmfordamm of
.
the work for which 444 permit 4 Wood (Sec. 3097, Civ. C.)
"
Lender's Name
Lenders Add.
I certify that I haw read 444 application and sum that it= show Information 4
'
torten i a{me in comply with all city and county an ince, and some law relNng in
building construction. and hereby suthorha representstiws of this city m enter upon tie
above-mentioned property for inspection purposes,
(We-) agree N taw, indemnify and keep Modules; the City of Cupertino against
Iitbilities,Jadgmenu, ensu and expenses which may in my my accrue against said City
In
CANrc of the RSfANDS Ais peW t COMPLY WITH ALL NON-POINf
Issued by: Date
URCE R L ONRe-roofs
ITau
AZu US MATERIALS DISCLOSURE
Type Of ROOF
III Ne applicant or future Wilding aceupantsue orlu ale hautdaw material
defined by Ne Canadian Municipal Cade. Chapter 9.12. and Ne Health and Safetyde,
;tstfict?
Section 25532(x)?
All roofs shall be ins ected rior to an roofrn material beim installed.
P Y 8 gWill
CYes QIS�P
If a roof is installed without first obtaining an inspection, I agree to remove
Ne applicant or future Wilding =upam use equipment or devices which
i7 hmardous air contaminants u defined by Ne Bay Ara Air Quality Management
all new materials for Inspection.
❑Yes CNoo/,
I have mal Ne havNnusnfucdW requirements umlerCh p ar 6.95 of The Califon
n4 Health k Safety Code, to 15503,23 md25534.1 un demand On if Ne building
to
ams not cum)nlly of it 4'03 spovinility in notify Ne rceuPantnf ti7e
reyviremcnu n be rbi mm of,Cenificna
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner arisd a Dau'
C]
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS:
4 Cfi
PERMIT #
.�-6So0.7
OWNER'S NAME: Lea
PHONE #
GENERAL CONTRACTOR e` 4 ,,
FAX # I-) og' -370 Z6 J(
I am not using any subcontractors: S� 3 B 5
t ure Date
Please check applicable subcontractors and complete the following information
Owner/ Contractor Signature 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/ Contractor Signature Date
11
OF
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER /
PERMIT APPLICATION FORM
APN # 6 2 O
a (4Z
2-0
Date: 5 3,c> S
Building Address:
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
Owner's Name:
Business License
Phone #:
Contractor:Phone:
0 028 3 70 355 3 S
License #:
Scr>
v - c
Contact:1
Phone:
Cupertino Business License #:
11 eM
oL o VO 3S5 S9S0
Building Permit fo:
Bldg ❑
Elect ❑ Plumb Er
Mech ❑
Job Description:
144
W
Residential Imo'
Commercial ❑
Cost of Project:
7d�_
Strapped On Platform Bonded El
New Location E]Replacement
�—
Qty. if
Annlicnhle. Fee M
Fee Descrintion
Fee Groun
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
G