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04010010 CITY OF CUPERTINO BUILDING DIVISION PERMIT - (-'f?NT 12A.C'TR INFI)I.tMATTION • h NY.... ,.rt w ". BUILDING ADDRESS: WATER HEATERS ONLY PERMITNO04010010 OWNER'S NAME: PERMIT ISSUE DATE T NE: SANITARY NO. CONTROL N0. ARCIIITECf/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 E 0 0 X00 LICENSED CONTRACT'OR'S DECLARATION - 1 nemby affirm Thar I am licensed node,provisions of Chapter 9(emprommmg IOb Description with Sermon 70(0)of Division 3of Joe Busincxe and Pro ,andmyliecnec is �'��® eta Lianimc�ndett. 3 /' g 3� REPLACE WATER HEATER - ARCMI rose DECLARATIO casan I undcrstanJ my plans shut]Wused es PUM1lie records JAN 2 6 2004 Jyp Licensed Pro(essmaa <S OWNER-BUILDER DECLARATION BUILDING f 1 hereby maso arfirm on )oro exempt froms an the Contractor's License Law for Inc p O following reason.(Section]1131.5,Business and w,de ons h.Code:Any tiny st county K m which rcyulres a permit nr construct,elleq improve,demolish,or repair anystructure yZi prior In its issuance,also requires the applicant for such Permit to file a signed Statement pp2< that he is licensed pmse.nun the provisions of the Contractors License Law(Chapter H Sq. Ft.Floor Area Valuation yt$ (commencing with Section'/000)of Division 3 of the Business and Professions Code)or y Nat he I.exempt therefrom and the basis for Ne alleged eaemption.Any violation of rANAi�1.}a�w.A Section]031.5 by any applicant for a permit subjects the applicsnuo a civil penally of 3 Waf1D.g VA*Qr00 Occupancy Type not more Nan five hundred dollars($500). ❑1,u owner of the property,or my employees with wages u their sole compensation, will do the work.end the swcmm is at intended or offered for sale(Sec.7W,Business and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements am not intended oroRered for sale.If, however,the building or improvement is sold within one year of completion,the owner. builder will have the burden of proving that he did not Wild or improve for purport,of "lode ❑1,as owner of the property,am exclusively contracting with licensed convectors to construct the project(Sec.]Oda,Business and Professions Code:)The Convector's Li- come law does not apply to an owner of propeany who Wilds or improves themon,and who contracts for such projects with a contractods)licensed pursuant to dm Conlan 's Lvenm L,- 0 I tan exempt under Sec. ,B&P C for this reason Own Dem Owner WORKER'S COMPENSATION DECLARATION Ihereby affirm under penalty of perjury one ofnhe following declarations: ? have and will maintain a Cenificam of Cnnscnt to m161nsurc(or WorkersCompen- '�'\ son,u provided for by Section 3]00 of the labor Code,for the perfarmenm of the - J work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance.as mquircd by Section 3100 of Ne Labor Code,for the performance of Use work for which this permit is issued - MyWorkelsmpewlic Inesmnce,carrier and Policy number am: Cartier. Ts— A— Policy No.: 51/ 3 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W complemd if the permil is Toro echundred dolls s(SIDE) or less) 1 certify That in the performance of the work for which this Permit is issued,1 shall not employ any person in any manner so as lis become subject to the Workers'Compensation Laws of Caiifomia.Dam Applicam NOTICE TO APPLICANT:If.after making this Cenifimm of Exemption,you should become subject In the Worker's Compensation provisions of the Labor Code,you must .J z forthwith comply with such provisions or this Permit&hall he deemed revoked. „zi7 CONSTRUCTION LENDING AGENCY [- nIhembyaflirm that thea is a construction lending agency lir the Performance of ell rte+ the work fur which this permit is issued(sec.3041,Civ.C.) Is] A lsnder'a Nam. - ZDz Lender's Address V Q 1 certify that 1 have read this application and vele that Joe above information is ILE consul.1 agme to comply with all city and county.o inances and state laws miming to O building Conswction,and hereby authorise reprcmmatives of this city to enter upon Be 4 ah.va-Mari oned pmpcny for inspection purposes. (Wit)agree to save,indemnify and keep harmless the City of Cupertino against Hfn liabilities judgments,costs and expenses which may in any way accrue against mid City V z in consequence of granting. this il. ti APPLICANT ERS D ILL C LY W?TH ALL,,,NNNON-��9000INT Issued by:9102� Date SOURC Da Re-roofs f, Signawrc of ApplicaDam MATERIALS DISCLOSURE Type Of ROOF U HAZARDOUS Will the applicant or forum Wal Co t,Cham no�e2,handle Health and u defined by the Cupertino Municipal CWc,Chapmr 9.12,and the Health and Safely Code,section 25532( sw_ All roofs shall be inspected prior to any roofing material being installed. ❑Yon I Will the applicant or futuro building occupant use coaipmem ser Jcvicet welch If a roof is installed without first obtaining an inspection,I agree to remove hazardous air c.nmminanb u defined by the Bay Area air ouallly Management allnew materials for inspection. act? ❑Yes IykNo� r ' I hent real the Wzsrdnus ntmeri.k mquircmcnls under Ch.ple,6.95 of the Califor- Id. ealth&Safcy Cade,Soedou25505,25533 and 25534.[understand Ow lfthe Willing nm currently ha a he I,Nat it u resp.nsihility m notify the oecup rat of the imm.nu wMc ustW mel 'or .a anee.ra threaworoca aybI, Signature of Applicant Date r[!/'S/ ° All roof coverings to be Class "B" or better Owner ora IhorizcJ agent Dam ' • CITY OF CUPERTINO WATER HEATER CUPER,TINO PERMIT APPLICATION FORM APN# 36 Z / / ty f / Date: A Building Address: F-0 3 S O /`G w 7✓/L Owner's Name: / Phone#:-11 Z S 7- S 2 3 Contractor: License#: -3 -7e/,573 Contact: Phone#: - FOD 635 -,5946 Applicant/6eff4aetor: • - DJ•�- � �Si o� S y�—/23 z Building Permit Info: Bldg Elect ]umb Mech Job Description: esidential BUJ Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: Valuation: 8So • cTt7 Type of Construction: Occupancy Group: Qty. if A licable Fee ID Fee Description Fee Group / BENERGY Energy BUILDING BPWHEATER Water Heater/Vent BUILDING / PPERMITFEE _71—umbing Permit Issuance PLUMBING BPERMFEE Bldg Permit Fees BUILIDNG BMITIGAT Housing Mitigation Fee BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG f