03090145 j1CI'('Y OF CUPNRTINO A""� ¢ s� � '' azx�•''s ;
BUILDING DIVISION PERMIT CONTRACT INFORMATION
• a UILDINGADDRESS: PERMITNO03090145
qezq7 Pr)VAT ()AK WY
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
rat
0 0
+Oo LICENSED CONFRACTOR'S❑ECLARATION Job Description
F m I hereby.from mm
at I am licensed under provisions of Chapter 9(comencing P
with Section 7000)of Division J of the Buaincxx dProessionsC dc,a liccnuis
x� N
in full fnrc ape err ? REPLACE WATER HEATER FIIVAd.E®
jq? License LIc.M
'gr°y Dam ARCHIT[CI'SDc ATIO � CONTRACTOR: RMCI BUILDERS
IC I and a d my plans shall he used as public meordi OCT 2 3 2003
SyU
e LLo Licensed Professional
3 OWNER-BUILDER mDECLARATION BUILDING
C 0 0 1 hereby afnrm on 1 am exempt from Nc Contract
or's :License Law for the
p0 followwhichinguiresa Permit
]1nstr Business and Improve.
dernns Co de:Any city or county
S$v, which in
n issaneemso toconstruct,eluc improve,dcermitt ore a sig any structure
-zi thione iuissusd Portan,totalhcapplicant fur Nchpmmhre Reese Law statement
2iC (commthat he eacwnwJpurstion7 )nCDivistun Othe rtho urines adPritclawoCoaCl9 Sq. Ft. Floor Area Valuatio$1950
z H that
exempt
ereft rn and de,basis f J oftheeged Business end on.Any
laden of 4
Nu io u 5 bthcrtfrem and the burs for the alleged exemption.Any lineation of 1ai.wn' {,
Eamon]B]LShyany
undred dollaronpermit subjeeu Be applicant loacivil penally of 341Py],a,0ijnbgr00. . _ . Occupancy Type.
not marc than five hundred dalton($500). '"' ""` ----
0 I,a owner of the pmpeny,m my employma with wager u their uec mmpemalion,
willdothework.and the swcture is not intended moffemd for sale(Sec.]044,Business Required Ins t'
and Profcuions Code:The Conmmars License Law does not apply N an owner of ❑y it R
property who builds or improver tureen,and wh.doesauch work himself.,through his SO2 - FINAL PLUMBING ENERGY
awn employru,prodded that such improvements are not intended or offered for sale.If. 506 - GAS TEST
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 build or improve for purpose of 507 - FINAL PLUMBING
❑ I.as Owner of the properly,am exclusively contracting with licensed contractors to - ---
conserver the project(Sec,7044,Business and Professions Code:)The Contractor's Li.
come law does not apply to an owner of propsi who Wilda or improver themon,and
who comracu for such projects with a contractor(s)licensed pursuant to Ne Conmclors
License L.
I am exempt under Sec. ,B h P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pe jury one of the following declarations:
I haus and will maintain a CerdOcale of Consent m self-imum for Worker's Cumpen- ,
s-lion,u provided for by Section J]W of she labor Cade,for she performance of Nc
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
J]W of Ne Labor Code,far Ne performance of the work for which this permit is issued.
My Worker's Compensation Insurance car and Policy number am:
Ca er• .Bey No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not tecompleted if the permit is faone hundred dNlvs(f I W)
lass.)
I ceoify Nal in the perGmnp c of t�wm:far whirl(ul i permit is iuucd.I shall nut
employ any pc y a r I e Om s 6 t hCNtoleral wropcnsatom
Laws of Calif. a
Applicant
NOT] 0 APPLI A :If,after making thi ¢ase of Exemption,you should
beta subject 10 the Worker'.Compensation previsions of the labor Cada,you most
D O forthwith comply with such provisions m this permit shall W dimmed favored.
Z: h CONSTRUCTION LENDING AGENCY
I herchy am.Nat there in comuunino landing agcney for the performance of
SS > the work for which this permit is issued(Sec.JW).Civ.C.)
.y Q Lender's Name
2 Lender's Address
J C 1 worry Nat 1 have read this application and sum that the above informuiun is _
y H correct.I agree to comply with all city and county ordinances and state laws relating to
V building construction,and hereby nuthnrim repraemuives of this city to color upon the
1 above-mentioned properly for inspection purposes.
(W I agree ve,Odemntfy and keep h ss the City of Cupcnine against
r rA. iiabilitI"It""g nts, ossa and expenses which i any way eccmc againA said City
;J 7 in mnscyuen oft gra tin dlsome, r.
AP LICA U ER S ❑ I PLY WITH ALL NOry/P01 Issued by: Date
SOURC LAT] /s
(// Re-roofs
n ser a Appli nUContramorDa
HAZARDOUS MATERIALS DISCLOS Type of Roof
Will Ne applicant or
future 11'ding uccupamsmrc.handle hammed,mamial
as damned by the Cupertino Muri rilCode,Chapter 9.1],end the HaRh and Safety
Code.Senion-------)? All roofs shall be inspected prior to an roofing material being Installed.
QYes Na P P Y g g
Will the spinae,or future "ding occupant sew cquipmcat or devices which If a roof is installed without first obtaining an inspection, I agree to remove
"hmardnm airconuremonu dm(ined by Ne Bay Arta Air Quality Management all new materials for inspection.
iarict?
❑Yes
I have read the 'sea nus materials requirtft is under Chapter 6.95 of the Gli for
ma HcalNhSafel .Sjcdo.25N15. E-(J 5J4
.I undersand thuiIt� ildi
docs not cummm As rve6✓Icnan,do it i sp sihiliey an nndl'y Ned,cup l n e
requirement ich sl n` f cors Ccnifica"Q'S m
9 Signature of Applicant Date
.Or raullimu.daie Dalo All roof coverings to be Class"B" or better
CITY OF CUPERTINO
WATER HEATER b ° qS
CUPEkTnvo PERMIT APPLICATION FORM
APN# Z I Date: / 3
Building Address:
22 12
Owner's Name: Phone#:
Zoc o i c CC. . y � U76U
Contractor: Phone: License#:
LJ 06, b�
Contact: Phone: Cupertino Business License#:
001mi ?
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ,Id Mech ❑
Job Description:
tL
Residential� Commercial ❑
Cost of Project:
J �
• Strapped . n Platform Bonded El
New Location Re laceme
Qty. if
A 1' a le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING