05040141 CITY OF CUPERTINO ' &axrra"9N.7m�hrok r
BUILDING DIVISION PERMIT ,�i,'FIKOTQR T,NF,OR.
BUI
LDINGADDRESS: PERMIT NO.
HOT WATER INC 05040141
RB
M PERMrrrSSUEDATE
NE: SANITARY O8494
L NO.
ARCHITEC IENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH l�
�oz LICENSED CONTRACTOR'S DECLARATION Job Descriptio
et 1 hereby affirm Division
1 w licensed under previsions of Chapter n(mmmcneing
< with Section WorbyR)ofn that In3oftho Bualeaend Pfoons of hapten 9(Comd my menseh
p in full force and affect. T
py Llttnw❑ ue.x �-� REPLACE WATER HEATER
IIF-- Dne Conlrwitr
ARCHITECTS DEC O �I
1 undemanJ my plans;shell ha used as public me ON
4 C Licensed Pmf.mianel J
OWNER-BUILDER DECLARATION
E I krchy afnrm that I am exempt from the Conrramm's License Lew for the
0 o following reason.(Secdun 703I.S,Business and Pmfaulons Code:Any city or ceumy
$ which requires a Permit to anneal,alter,Improve,demolish,or repair any Structure
prior to its issuance,also requires dw,pplinnt for such perm0mI'll...iguedmaterecou
G
that kisltcwucdpunusnuothe provisions ofNeCWtomi M1Lceruelaw(Clapter9 Sq.Ft.Floor Area Valuatio
_ (commencing with Section 70M)of Di,fow.3 of Ne Business and PmkAm nCudc)or
$
that he is exempt therefrom and the buts for the Alleged eumpllon.Any violation of
Section 70313 by any applicant for a permll subjects we appRunl to A civil penally of ,�ypl,r�ke'p�Ia Occupancy 7YP
not more than five hundred dollars($500). 3,'Otl LLVV!R'00 . cess araC C
❑1,u comer of the property,or my employees with wages As their rule Compensation,
will do the ww4,and Nemoscue is not intended on offend for sale(Sec.704/,Business Required Inspections
end Professions Code:The Condamine,Lke w law dote e ns wt apply n an Men,of 9 P
property who Wima de lmprons Nomo,and whodms,nhwort himwlfw through his
Own employe,provided that such Improvements an not Intended oroffe ed fee Ne IT,
however,Ne building or Improvement Is sold within one yew of compleddn,the owner
builder will have the burden of proving that he did not Wild or Improve for purpose of
saw I.
❑I, a owner of the property,am exclusively contacting with licensed cam mucid,to
[.moan the project(Sec.IWC,Business and Profusimu Cade:)The CnndwmM1 Ll-
nom,law does nor apply to an owner of property who build,or Improve,Neeson.and
who contracts tat sucle pmjcca with a eonv acmr(s)licensed pursuant to the contractors
License Law.
❑I am exempt under See. ,B&PC for this noon
Owner Dew
WORKER'S COMPENSATION DECLARATION
1 hereby a(Ibm under Katy of perjury am of the following dwlantiom:
I ham end will mAinuln•CeNOnn of Conwm to¢If-locum fee WwkeM1Cmnpem
don,u provided fee by Section 37M of the labor Code,fee Ne performance of fee
work fo which N6 permit i,iuved.
hem and will mainroin Wortrrf Compensation Insunntt,u required by Section
1110 ofthe Labor Code,fee the performance of Ne work far which Nla permit ts lasted.
My
worlwe Cwtlperyalion nsunnca carrier and y No.:nu jf�rt 1
Cartier. Poliry No.: J
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This w.tim need net be completed If Iha permit Is force.hundred dollen($IM)
or less.)
1 cenify that In the perfa ansae,of the work for which this permit Is issued.I shell not
employ any person In any muner an As m become:subject be the Wwken'Compennlon
awaof .CalifomICD
LA
au u .O
pplin¢ 11--��
NOTICETO A CANT:If,titter making this Cenibcaw of Exemption.you i�iul-
become subject to the Worker's Compenu0on provision of the lakr Code,you mum
Q O forthwith comply with oath provision,w this poralI shall k deemed revoked.
pre CONSTRUCTION LENDING AGENCY
[tet Ikreby AM,.NU than,laaenn asedon lendingagenry,for the perform.of ,
the week for which this permit 1,land(Sec,51191,Cir.C.)
ltI Q Leodees Name
a z Lender's Addmss
V Q I certify that I have read this pplication and saw that the sham Infmmait.Ie
correct.I agree to comply wife all city and county ordinance,and Ante hose nlming in
Q SV^ building construction,and hereby authorize repmeenwivea of Nis city to enter upon the
{+7 ebovumemioned property for impaction purposes
gy (We)agree to an.indemnify and keep hrtmleu the City of Cupenino agalost
M Ilablllllu,judgment,cuts and expone which may In any my amus.,Awm said City
fjT In consequence of Ne gaming of this perMt. tAl�
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApplinO Dew
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII hApplicant Or future Wilding occupants stow or Iundle allousSwtlal
U deRmtl by the Cupertno Municipal Code.Chapter 9.17.and tk Health and
Safely
Cade,Scetion 15531W7All roofs shall be inspected prior to any roofing material being installed.
0 Yea
Will the. Rant or future Wilding Occupant use equipment If a roof is installed without firs[obtaining an inspection,I agree to remove
Ire 6 P q prem hr deme Management
Irict? mdreomaminntsumind byIhaBryAWN Air QualhyManagement all new materials for inspection.
wia7 /
❑Yes 6N0
Ihe.reW the Murdmnm 5505, requirements 55 under Chapter 6.95 tOf ime building
ole Health As mollafety Cadeard.,sections merims5A3anJnts un1r ChaptM.95f to Wilding
time not cmremly hum a mount,that II is my responihillty to Amity the mcupam of the
requi n -��n�ha met prior m wurne.a.Certificate of�mp/enry�- Signature of Applicant- Date
Own,or artnn�,z�' �� T— D/M— All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: � PERMIT # W 0� f
0 ar
OWNER'S NAME: a pyl �,/� S PHONE # -
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 f i( C,
Roofing
Septic Tank
Sheet Metal
Sheet Rock
�yTile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER 0 S"� � -I
CUPERTINO PERMIT APPLICATION FORM
APN# '35 C)C) Date:
-/
Z � ,
Building Address: art' 9-/L
Owner'sQ Ph #
Contractor: HOT WATER, INC. License#:
963 INDUSTRIAL ROAD UNIT 1 -
Contact: Phone: Cupertino us nes License#:
Building Permit Info: — /
BldgEl _ Elect ❑-_ ._ Plumb 1iy _ _-._ . Mech ❑
Job Description:
_ -- 11
__G� fc_�_l�P � �ersm�c_ 2eslra��/� itp
Residential Commercial ❑ E4161a—
Cost of Project:
Strapped ff On Platform -"" Bonded-T I =='�= '�'^�"'• "
New Location ❑ Replacement (�
-- -Qty.-if
A'licable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
y� 0
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