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05120074 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTORtINFORMATION BUILDING ADDRESS: AFFORDABLE WATER HEATERS P"""N0.05120074 22031 RAE LA OWNER'S NAME: PERMIT ISSUE DATE GREEN WINFRED JR AND TERESk 24707 SAN FERNAND D 12/14/2005 NE: SANITARY NO. CONTROL NO. (661) 259-7131 ARCHITEC rENGINEER: BUILDING PERMR INFO BLDG ELECT PLUMB MECH 0 0 uo00 LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm Nat 1 am licensed under previsions of Chapter 9(commencing Job Description with Section 7")of Division 3 of the Business and Profession Code,and my Iicemn is o ina OtBformandeff Lm g REPLACE 75 GAL. WATER HEATER Li<cn o ARCHTECD-S DECLARATION ECLARA I N k G ' � 1 undersand my plans shell he used as public rcrnNs DaU ky Licensed Professional OWNER-BUIIAER DECLARATION iI 1 hereby affirm that 1 am exempt from the Convector's License Law for the 00 following mann.(Suuon 703 L5,Business and Pmossion Cade:Any city or county 2 which requires a remain to construct,alter,improve,demolish,or repair a.Y suuctme $400 —iy prior to its issuance.also requitu the applicant for such Permit to rile a signed statement < road lux islicensed pursuant mthe Pownionofthe Conuxar,Lice selaw(chapter9 Sq.,Ft. Floor Area Valuation YFp (commencing with Section 7000)of Division J of the Business and Profusions Cutlet or y that he is exempt therefrom and the basis for the alleged exemption.My violation of n Section 7071.5 by any applieun for a permit subjects the applicant to a civil penalty of not more Nan five hundred dollars(S50(), r yAOccupancy Type C]1.as owner of the property,or my employe=with wages as their tele compensation, /e // Al will do the work and tiro trumure is not intended or offered foralc(See.7061,Booms. � S and Profession Code:The Contractor's Lian =not apply to an owner of �e Law tloIn peiio property who Wilda mimpmves then o t,andwho dmsamh work himself orthrough his v own employees.p building or i provehimprowmentsaane year mdWoroltion.for sale.If. O huilder,Nebuildinguimprovementismid within one year of completion,the owner- is builder will haw the burden of proving that he did not bulb or improve for purpose or (/ sale.). ❑1,as owner of the pmpeny,am exclusively contracting with licensed convectors to construct nt dm es not apply 7814,weer of and ray who Cade:)The Cs,themor's In- ane law does not apply e ts owner of property,who builds or improves Coreon,and whocontractsLaca for such projects with a conwcmrts)IiccmLad pursuant m the Convatab License ❑lam eaempn untl=S=. ,Bk PC fm Nix me=an Owner Date WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury aro of the following declarations: _ '\ Ihaw end will meinuina Cenifiaaa(Co,anttoalf-insure fm Wotkcls Compere union,as provided for by Section 37W of the labor Code,for the performumc of the work for which this Permit is issued. ❑1 have and will maintain Worker's Compensation Buura ce,u required by Section 37W of the labor Code,for the performance of the work far which this Permit is issued. My Worke'sn Ip'Tn(� 90lnamvx umm and Poll cyn tuber art: m Cormier 1•y' �/.�p.r✓I� PolicyNO.: 3f'=`z. ) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE - Couls action need no Wcompleted from Permit is for one hundred Johan($100) or lcsa) I certify that in the performance of the work for which this Permit is issued,I shall not employ any person in any manner an u m become mbkn re the Worked Comrewuon Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making this Ccnil eam of Exemption,you should b=ore subject on the Worker's Compewtion provisions of the laMr Cad,you muse .J O forthwith comply with such prevision or this Permit shall be doomed revoked. z CONSTRUCTION LENDING AGENCY [—a 4 l he rebywhich thi that there is ed(Sm.3W7,ding agency for the Performamc of C4'7 the work for which Nu permit u iuuctl(Sec.7097,Civ.CJ U=z Lender'..Name z Lentleri Address U C) I certify this 1 haw read this application and sate that the above infomudun is D.r. COMM 1 agree to comply with all city tib county ordinances and state laws relating to DU building convection.and hereby Authorim representatives of this city to enter upon the �+a above-mcntianc0 Propcny for inspection whims=. f-' (We)Agra to ave,indemnify and keep leatmlc s;the City of Cupertino aSaint liabilities,judgments,costs and expense - fn s which mar'in any way eccrvc agaimmu to City Uz in consequence of Ne granting of this Permit. APPLICA UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S ' G LTIOlS ! y / YY�' �2j !� Re-roofs Signature of Appli _HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof Will am applicant or fissure building occupant atom orhandle harudoa material a tic6rmd Ile Cupertino Municipal Code.Chapter 9.12 and the HcaN and Safety Code,Seb'..i255J2(a)4 All roofs shall be inspected nor to an roofing material being El Y. t7L16 P P � Y g g installed. Will the applicant orfuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove = it hafdous air contaminants a ncd by the Bay Area Air Quality Management al I new materials for inspection. isvics? ❑Yes Nu 1 has mad the hvardeesma crialstcquirements under Chapter6.95 alike Califor. nix Herd"Safely Cade,Smuon255(6.25533 and 25531.1 understand thuifum building docs not currently vc tenaL OAl II u my mspomihility to notify de occupant of thc meghire �lr be`Yprin uantta(aCerdfi=mar P=rey./ Signature ofApplicant Date /2 �7/ Owner or amhomed agent All roof coverings to be Class"B"or better pea 11/23/2005 08:49 66122599556 AFFORDABLE WATER HET PAGE 03/03 CITY OF CUPERTINO O S WATER HEATER OF CUPRKT[NO PERMIT APPLICATION FORINT APN# — 0-7 — �—7 Trate j 2 — `�_ D—! Building Address: �ats3 { )QAe I-u Owner's Name: Phone#i: W;n FrPa 6�C¢n o�- a5'a . '1$76" Contractor: Phone: �rO l License#: ab e a e eaTe�s ssl -1 ► cva-7 3L8 Contact: Phone: (c b{ Cupertino Business License#k: cou L-i1T 0-h'eld 5 o�av a�gsn Building Permit Tnfo: Bldg ❑ Elect ❑ Plumb Mech Cis Job Description: {�ePIGC.e 'js atlon WA'►"er bleaTer [5ctme IoCATi9n Residential Commercial ❑ Cost of Project: q o 0 • Strapped On Platform ❑ Bonded D New Location ❑ R5placement Qty. if Applicable Fee ID Fee Description Fee Group $MTEA ER Water Heater I Vent BUILDING PPfiRNIITFFE Plumbing Permit Issnance PLUMBING BENERGY Ene BUILDING BUSLIC Business License SUIT RING