03090018 2CI'I'Y OF'CUPRR'11NO s
BUILDING DIVISION PERMIT ~CONTRACTOR"INFORMATLQN.
i+ Y4e%.Ye M:
BUILDING ADDRESS: HOT WATER INC PERMIT NO03090018
79n Rr)T)RT(-T1Es Alt
'R'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
E: (650) 298-8494 SANITARY NO. CONTROL NO.
ARCHm C rENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUME MECH
L Q
±or. LICENSED CONTRACTOR'S DECLARATION [t
I m C I hereby affirm that I am licere,d under provlawas of Chapier 9(commencing 'V eJO�escription
aW with 5cgtion](NNq of DivOion Sof the Rosiness enO Professinnx Cole,andmylicenseis ` I -I
a is full/hrcpy
i'q� ueentLelas, Lies �" I Z WATER"✓HEATER('^
�t- Dau used As pts // 1f ✓tI,J,I
ARCIIITECTS DECLARA L U U
I I undersunJ my vlans shall he used u public mcnrN
G Loamcd Pndcssional
3 OWNER-BUILDER DECLARATION
<I 1 hereby affirm Nat I am exempt from the Contractor's License Law for the
00 (allowing rens...seetian 7031.5.Business and Professions Code:Any city or county
�$ which requires a Permit to construct,eller,improve,demoliah,or repair any structure
-Zi prior to its issuerace..h.requires theapplieant fineuch Fermium fie a signed statement
Ap that he is licensed pursuant 10 the provisioumfOrContractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
61- (commencing with Section 7000)of Division 3 of the Business and Professinna Cadc)or
$ that he is exempt thertumm and dee burs for the alleged exemption.Any viala4on of 35911011 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
......than Bw hundred dollars($500). APN Number, -- - Occupancy Type
-
Q I,as owner of the property,or my employees with wage As their sole compensation,
willdothework,and Neswnurt ismotinunded woRertd tarsale(Sea]OM,euainug _ FINAL
And Professions Code:The Conmanh License Law docs not apply m an ower of C
Property who builds or improves thereon,and who doesauch work himselfor through his 506 — GAS TES
main employees,provided that such Improvements Are not intended or offered for sale.If. SO7 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion.are owner.
builder will have the burden of proving Nat be did not Wild or improve fur purpose of
ole.).
Q I,as owner of the propeny,am reclusively contracting with licensed contractors to
consumer the project(Sec.7014,Business and Profession Code:)The Conuacues Li-
ceue Law data not apply to an owner of progeny who Wilds or improves ftmon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contra noex
License Law.
❑l am exempt under Sec. ,B,k P C for this moon
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations.
I ban and will maintain a Certificate of Consent to self-insure for Wallace,Compere
cation,u provided for by Section 3]00 of the Tabor Code,far the performance of the
work for which this pewst is issued.
�I have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the labor Code,for the performance of Ne work for which Nis permit is issued.
My Worker n .arson Insurance eerier and Policy umMrert:
Cartier. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=It.reed not W completed fruit Irowit la forme,hundred dollen(ir)(1)
or lux)
I cenify that in use performance Of the work for which this Permit is issued,1 shall not
employ any pennon in any manner an u to become subject to the Workers Compensation
Laws of Caltfoarm Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you mut
�O forthwith comply With such provisions or this Permit shall W deemed resulted.
z` CONSTRUCTION LENDING AGENCY
1 herehy a0)w that d¢rt is a commuction lending agency for the Performance of
Y ti the work far which this Pewit is issued(See.3097,Civ.C.)
't1 Q lander.Name
z Landers Address
J Q 1 cenify that I have read this application and sure that the above infowatmn is
y (~ comet.1 agree to comply with all city and county ordinances and sure laws totaling to
V building cmnstroction.and hereby authmberepresentative.of this city to enter upon the
J+U above-mcationed provenly for inspection purposes.
y (Wen)agora 1....indemnify and loop hawlcu Ihto City Of Cupertino against
cn liabilities,judgments,costs and expenses which may in any way accrue against mid City
JZ in consequcnee of the granting of this permit
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N"POINT Issued by: Date
SOURCE REC"ATIIONS.
' I X Re-roofs T
Signature ofxipplicant/Clikonchar
HAZARDOUS MATERIALS DISCLOSURE �a�` Type of Roof
Will the applicantor future building occupant stere car hmtdle harardaus material
As dermad by the Cupertino Municipal,Cods,Chapter 9.12,end the Health and Safety
e.Seaton 25532(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant us!cquipmenl ortlevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hanrama airconuminants ufned by the Bay Ama Air QualityM.nagcmcnt all new materials for inspection.
Diarict7 / p
QYcs Nn
I have mad the hmardmus materials mquircmcnu under Charter 6.95 of the Califor.
ria Health&SafetyCode,Sections 25505,25533 and 25534.1 unJers mrd On if the building
d¢s
not currently haw a tangnL Nat it is my resparuihil ity to rami ly the occupant of the
tequircmcnu which be met faormissuamceofa Ccrdfcatcof Occu c. Signature of Applicant Date
Owner oramm�<aag��T � O 3 g All roof coverings to be Class"B"or better
CITY OF CUPERTINO
acifyo
WATER HEATER
*CUTINO PERMIT APPLICATION FORM
APN # Date:
Building Address-
Owner's Name: Phone#-
7q
:
qe),g 9s'�—,)o 77
Contractor: Phon .ZLicens #:
— . �
Contact: Phone: Gj i H Cupertino Business License#:
Building Permit Info:
.Bldg ❑ Elect ❑ PIUMV0 Mech ❑
Job Description:
��'�R— l%riL / �fJv/�G�/�✓
Residential Commercial ❑
Cost of Project: �y
O �
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Re lacementla
Qty. if
ApplicablA Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING