05020152 CITY OF CUPERTINO F .
BUILDING DIVISION PERMIT i,CO It'ACT�URIl!Tk'QRMATIQN
BUILDING ADDRESS: HOT WATER INC PERMIT NQ 5020152
OWNER'S NAME: PERMIT ISSUE DAM
DAVID MARCUS
ONE: SANITARY N0. CONTROL NO.
(650) 298-8494
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG - ELECT PLUMB MECH
0 0 0
�o Zp LICENSED CONTRACTOR'S DECLARATION Job Description
M 1 hm N
hereby Mm et I am tkenscd en
under provision of Chapter 9(commcing
with Section 7")of Division 3 of the Builnc s and Profcasinn Code,and my license is
in full form and e m 0 '
m� LkenseClw Lk.g REPLACE WATER HEATER.
D.te Comrsaar
ARCHnECTS DECLARATION
'yS I underiumd my plans Mall W used u public records
3 U
5� Licensed Professional
OWNER-BUILDER DECLARATION
+�1 i I Wreby.(Sero that 11. exempt from the Cssions o License Lew for Ne
19 following meaon.Permit
t 7031.5. t.shm. and Professions Code:My city or county
which mquima•prmit re construct.alter,improv,dTamil t w e A sig any structure 00
v.tai pdomsliccoadpumaretothe Novisios of fwuoehpermism Bleuigoedwmmcnl
ggg O (comm iniwitPuteaan700MofiionsOfNc cBusi asank<onlaw(CMpkr9 Sq.Ft. Floor Area Valuation
$ that m is exempt
therafroun n d the
bssDivision 3 th the alleged
ex and Proon.My m Code)or
Wt ha u asempt ra•,.from and the bum for dm alleged esrsnpaM.My WolaJon of
Sedo.7N.�a b�nneedlAantforollars permit
e itublda7atheapplicant toacivil penhyor 00 Occupancy Type
❑I,ummrof0 Koperty,wmyempioycrwiNmgesulWlrmiemmpenugm,
will do thewad,and the structure is notiatended An oReud fonale(Sec.7044,Business Required Inspections
and Professions Code:The Contncmfs Licensee taw does not apply W an owner of q p
owns enywyeta,provided
dust s himpoandwho dassah wok himuHwllwugh his
awncer.the iprovided thatvemimPssold wiitartmit ear ded ofcwpaesed for owner..
builder,the Wilding u den of proving
g sold a did
Am year of Improve for the owan
builder w10 have the burden of Proving Nal he did not WIIO or Improve for purpose of
ankJ.
❑1,As aver of the(Sec.7044.
dues Andlusively carousing With 11"NausTW C conummn W
cwutma d project(Sec.7014,Buinm and Py vvion wilds
Code:)Theves the
Wra I.id /O/
Genu taw dila Much pr a an own.of properly who builds or improty Norton,and,
Lwho t..L cu for such projects with veonvuWrtq licensed pursuant W the Canaanora (�
Lienee Law. S
❑Lem exempt under Sea .BAPCfor this moon
Gwnr Dan
WORKER'S COMPENSATION DECLARATION"
1 hereby affirm under penalty of perjury aro of Ne fallowing declarations:
❑l have and will maintain,CeNftcam of COnaenl to Rlhlnsumfar WokeraCampen-
.Ilon,u provided for by Section 3700 of the labor Code.for the perforeamue of Ne -
workf which Nu permit is humid.1 hove and will maintain Worker's Compensation Insurance.As required by Section
3700 of the tubo Code,for the performance of the work for which this Permit is issued.
My Worker',CJnp_peasad n Inwnnra artier end Policy number
Cartier. S�e Fu K Policy
Na.: 15V -3 Io
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tnissectim need not Uncompleted lithe permit is for one hundred dollen(1103)
or lo..)
I certify that in the pUlleMmee of Ne work for which this Permit 4 issued,l siull not
employ any person in my manner an As W become subject to Ne Workers'CompeuaBon
Laws or California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject In the Workers CommnsNon Provision of the labor Code,YOU mot
.JO faMwinh comPIY with each provisions or this permit shall be deemed revoked.
z CONSMUCfION LENDING AGENCY
(~ I hcrchy affirm that Neu is comucninn lending agency for the performance of
Ri the work far which Nu permit Is issued(Sm.3097,Civ.C.)
aUnder'.Name
a.z landeMd.'.Md
U0 I ttN(Y that 1 haw read oda application and sate Nn the shove infwmNa is / /
C)^" building i agree ct comply with all city and county ordinancesOSOf and rote lova relating W / 'Jr�I//� 15
atmi.ngconsuucliogandhemby Authorize nites of Nis city to enter upon Ote _
W shove(Wc)a agree
Property for InspectionIndemnify
M purposes.
keepI
(We)ague to cove.Indemnify and kap harmless the City niCupertino against
In in consequence
o themeuand expenses isPCMIich mrylnany wy Gera against Wit City .O
t.)7 A APPLICANT
of UNDERSTANDS
of NisD WILL
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH A Ni Issued by: Date s
SO/y1j��RiC{�ERE,C,ULA�TID�N5S�✓//�� � �
Li'VWJ .YYfLdt,k.l. a - Re-roofs
Signature of ApplianVConuaaor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm building occupant nam or handle havardaus material
de0ncd by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safely
Ode,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yoe 019.
Will the applicant ata furore Wilding occupant use equipmcm w devices,which If a roof is installed without first obtaining an inspection,I agree to remove ,
mit hoiardnm airmntaminmu as,defined by the Bay Area Air Quality Management all new materials for inspection.
Dianna? __//
❑Yes 9K.
tnaverealtheha msmmdaise immenuunderChapwr6.95ofthe Ctlifom
ntaHalNkSafetyCodc,Scaian235DS.25533VW25534.Iundentamd Nuifde Wilding
dila Mt currently have a tenana Nat it u my responsibility W Mary tic amuPant Of Use ye'�tirii
fey mmtawhibnmaatJW��r/�_rp�eo�rW(a�/J�,aea.�a,d�ar�.ceNlm,kar99��mP i Signature of Applicant - Date
DZt.,s—fR= a/s3 �S All roof coverings to be Class"B"or better
Owner or aohodved agent Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�
CITY OF Fax(408)777-3333 UPEkTINO
Building De artment
JOB ADDRESS: 50/ PERMIT #
aoza /v 116X t n &ro tet. 0S01015
OWNER'S NAME: CA v MQ re e t S PHONE # Yd ey-a 5 7 - loa7
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
66 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 off-/ 3-11
Roofing
,Septic Tank
Sheet Metal
Sheet Rock
Tile
a a3 vs
Owne ior Signature Date
CITY OF CUPERTINO o 'b 015
WATER HEATER S
CUPERTINO PERMIT APPLICATION FORM
APN# 3S � -d 7 —O �OO Date:
Building Address: 41170
2- ZZ. /(U Gt1/1�/' D
Owner's Name: Phone#:
a,uk h'larc s o9- a57- 7&2 7
Co tractor: Phone: License#:
1
t — 03/—g q /-/ —7& 3 62/a--
Contact: / Phone: Cupertino Business License#:
O:L
Building Permit Info: /
BldgEl Elect El _. Plumb 0 Mech ❑
Job Description:
914�tz-
Residential Commercial ❑
Cost of Project:
Strapped E3 On Platform El Bonded ❑
New Location ❑ Replacement,
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING