03100074 .� CITY OP CUP
ER7TN0
nuu.nwc Dlvlslory PERMIT CO,NTRACTOR`�INF(1RMATION,
p BUILDINGADDRESS; HOT WATER INC PERMTTNo03100074
1091 RED FIR CT
OWNER'S NAME: 2531 GRACELAND AVE PERMTT ISSUE DATE
'lin
A
ire: (650) 298-8494 SANITARYNO. CONTROL NO.
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Jet, LICENSED CONTRACTOR'S DECLARATION
a1 hereby affirm that I am licensed under previsions M Chapter 9(commencing Job Description
Section 7M)).f Division Sof Ne Businwand Profcaiuu Code.and my license isll force and of t
uceneelaa _{tLLic.a 14 � �" 12
WATER HEATER REPLACEMENT
iF Dames%• CetiARCHITECTS DECLARATION
i 1 unticrsmnd my plans shall k used a public records
i�
°off Licensed Pmfcssionel
r 3 Oat I am exempt N mDECLARATION
f 1 hereby.Priem that 11. exempt Bum Nc Conlon;Co :Any c Law for The
:O o which ng moon.(Section 71131.5,Business and ve a moll Code:Any city s county
5$� which rcyulma a Permit In ennWn,elmq improve demolish,or repair any structure
rod,to its iuuaazc.also requires the applicant for such permit T9 rile a signed statement
et< That he is licensed punuanttotbeprovisinunfftCmdrocturiLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
IFG (commencing with Section 70)0)nf Division J of the B ushom and Professions Conk)or 6 �
$ Nat he is exempt therefrom and the buss for the alleged dumpuon.Any violation of 135905032 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of /// ApN Number Occupancy Type
not main thanfivethe properundred ty,
or yemp. £
❑ I,uowner of Ne pnpcny,or my employees with wages as Heir wle compensation, //' /�✓ 1
will do Ne work,and Ne awaure is not intended or offered for ale(Sec.7014.Business k'11
/i C
and Profession Code:The Contractor,License law does not apply lf an rough is G cS�Tci,
property who builds or thereon.and who does such work himself or his f ��
awn employees,provided that such improvements are not intended or offered for sale.if, S NAL PLUMBI
however,Ne building or improvement is sold within one year of completion.Ne owner-
Wilde,will have the burden of proving that he did not build or improv for purpose of
ale.).
❑1,as owner of one progeny,am exclusively contracting with licensed contractors to
contact the pmjcct(Sec.7044,Business and Profession Code:)The Contractor's Li.
cease law does not apply an,an owner of property who builds or improve thereon,and
who comncts for such projects with a contrumrts)licensed pursuant in the Court
License Law.
❑I am exempt under Sea ,B&P C for this moon
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury on of the following declaration:
1 haw and will maintain a Ccnineou of Consent to self-inaum for Workeb Compere
scion,a provided for by Section 7700 of Ne Labor Code.for the perfonnontt of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,u required by section
W of Nc labor Code,for the performance of the work for which this permit is issued.
My Worker'.CnrmpenaJon lnsunntt carrier and Policy 2.1str a(rs, -,U
, 6
Cartier .fTd7 T/ Polity No.: _
CERTIFICATE
OEXEMPTION FROM WORKERS`
COMPENSATION INSURANCE
mils section road not keompleted If she Permit is for one hundred dollen($1010
or less.)
1 certify that in the performance of Ne work for which Nis Permit is issued,I shall not
employ any porton in any manner u as to become subject to the Workcri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making Nis Cardalu c of Exemption.you should
become subject to The Worker's Compewtion previsions of the labor Coda you must
0 forthwith comply with men provisimts or this Permit shall k deemed revoked.
Z CONS RUCr1ON LENDING AGENCY
1 hereby&Rom that Nem is coatructino lending agency for the Performance of
X tho work fur which this permit Is issued(Sec.3097,Co.C.)
QLender's Name
z Lender.Add..
J O 1 cer fy that I have mad this application and nee¢that the above information is
(✓ correct.I agree to comply with all city and county ordinances and roam laws r img to _
V building construction,and hereby anhoriw representatives of this city to enter upon the
Ii7 above-mentioned property for inspection purposes.
(We)agree to uw,indemnify and keep harmless The City of Cupertino against
(req liabilities,judgments,costs and expenses which may in any way ucom against said City
JZ in consequence of the granting of this Permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE L ONS. '(\�(� [/
Signature of pph�amruOOT � ` t pq/O\ Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building occupan store or handle hevardous material
as defined by Ne Cupertino Municipal Code,Chapter 9.12.end the Healdt and Safety
C
ode.Section 255320)? All roofs shall be inspected prior to any roofing material being installed.❑Yaa 19No
Will The applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
10 haurdnus oir contaminants as defined by the Day Arca Air Quality Management all new materials for inspection.
nric0?
❑Yu IFN.
1 have reatl the humandual hmatenals requimmeats under Chapmr 6.95 of the Califon
ri.Health a Sar.1yCeae.Sections 25505,25573 and 25$34.l unocnNnd that ifthe building
docs not currently haw a meant that it is my responihilily m notify Joe occupant of the
myuimmcnuhoe kmn onnissuarmeefa Ccnifcate of occpaPpy., Signature of Applicant Date
Owner or autnoriz dagent � / UUD,y All roof coverings to be Class"B"or better
CITY OF CUPERTINO
WATER HEATER a3
CUPEkTINO PERMIT APPLICATION FORM
APN# � O S d3 Z Date: /0 0 D�
Building Address
a) OW Xri)-� T/p- e-T
Owner's Name: P ne#
07 JkJ & /r`/6
Contractor: Phon License#:
�CYr w T� vtaC.. 2f �-�J�9�l G / Z
Contact: Ph Cupertino Business License#:
ws
Building Permit Info:
Bldg ❑ Elect ❑ Plumb/& Mech ❑
Job Description:
L) �"--
Residential Q) Commercial ❑
Cost of Project:
O
• Strapped On Platform El
Bonded
New Location ❑ Replacement/LCV
Qty. if
Applic4l1je Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING