03120068 CITY OF COPERTINO �a,� �yy� wry+ `�t
BUILDING DIVISION PERT.. d RE�. d^`g';y
auaDwPERMIT NO.03120068
HOT WATER INC 03120068
30455 SALT EERMANTLY) AV PERMIT ISSUE DATE
lt; Licenwd
NER'S NAME:
KAY CHEUK 2S31 GRACETAND A079
SANITARY OL NO.
ONE:
BUILDING PERMIT INFO
CHITECDENGINEER: BLDG ELECT PLUMB MECH
p 0 0 0 0
•1pLICENSED CONTRACTOR'SDECLARATION Job Description
I hereby affirm that 1 am it- u cr provisions of Chapter 9(commencing
Ngccti e-7 )ofDivision3ofmc isend Professions Codosndmylicemcia
^gyail force _ (- Lic.g 6 Z- REPLACE WATER HEATER w
n! enu Wes i FINA
IgJm G pRCHITECI'S CQmqcfa RATION
a �I aigra my It as a�bus d a public records
;tProfcstiaml�T JAN 2 2 2004
OW NER-BUILDER DECLARATION
F 1 herchy affirm that 1 am attempt from the Conaac m's License Law for the
O O following reason.(seed un 7031.5,Business and Piofcssiam Code:Any city or county BUIL
ING GG
which requires a permit m caromm.alter,improve,demolish.or repair any structum
prior to its issuance,also requtra the applicant for such permit to file a signed statement ValOatlO
H?Qthat he is licensed pursuant to the provisions of dm Connector's License Law(Chapter 9 Sq.Ft.Floor Area
$ (commencing with Scetion 70001 of Division 3 of the Business and Profession&Cadel or
that he Is exempt therefrom and the buds for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjecta the applicant se a civil penalty of 3.5S�ero(] Occupancy Type
not more than five hundred dollars(5300). .
0 1.u owner of the property.m my employees with wages as mets able compensation,
will do the work and the swctum is not intended oro@ted far We(Sec.7W,Business Required Inspections
and Professions Code:The Cantsacmcs r's License Law donot apply m an owner of q P
property who builds ser improves thereon.and who does such work himsel f ser through his
own employees,provided that such Improvements are not intended mattered forule,If,
however.the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that W did not build or Improve for purpose of
sale.).
0 1.as owner of me property am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contracters LI-
came law does not apply to an owner of property who Wilda or improves thereon,and
who contracts for such pmjeem with acomrmmrm)licensed purauenl to this Contowl0ea
License Law. -
0lamexempt under sec. ,B B P C far osis rrawn
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hemby Afire under Nulty of perjury one of the fallowing decluatlons:
1 have and will maintain aCerifiam of Consent m self-imam fm Worker's Compen-
smon,u provided for by Section 3700 of the labor Cade,for the Performance of the
work(or which Nie permit is issued.
0 I haw and will maintain Worker's Compensation Insurance.u raquhad by Section
3708 of the Labor Cade,far the Performance of the work for which this permit is Issued.
My Worker ampensellon lnaunme artier and Polity numWrye ��
Ca 'er. �✓� Policy Na.: S1 `� -
ERTIFICATEOFGgX ON FROM WORKERS'
COMPENSf IONINSURANCE
(This section reed nmbecompleted if the pere itis forom hundreddollars(510t)
or less.)
I certify that in the perructruce of the work far which osis permit is issued,I shall not
employ any person In any manner so as W become mbjw to aW Warkeri Compensation
Laws of California.Be
Applicant
NOTICE TO APPLICANT:IL after making this Co ificam of Exemption.you should
became subject to the Worker's Compensation provisions of the Labor Code,you must
�Z forthwith comply with such previsions or this permit shall W deemed mvoked.
r O CONSTRUCTION LENDING AGENCY
[ti I barely affirm the mere is a camWctinn lendingagemy fm me perfurmana of
C
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Addrns
U I cattily that 1 have mad this application and stsm that the show information is
W F comet.1 agree to comply with all city and county ordinances and slam lawn misting to
0V building convection,and hereby authariae mp.mati.of osis city m cam,upon me
W above-mentioned properly for Inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Taj) liabilities,judgments.coats and expenses which may in any way acerae against mid City
UZ in consequence of the ranting of this permit.
,-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE�Cf1EA NS. le 4 011 2�1(11q'Z
Re-roofs
aumof Appliam/ mass e
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or fume building occupanistore aa
mlatum hardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532m)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes
Will me applicant or mem Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil havardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes
Ihewread me latuarlousmancrials tequiremcnm under Chapmr6.95oftheCalifor-
niaHcalmASafetyCode,S 6ms2505,25533ud25534.Iundemmndthmtfdm Wilding
does not currently have a tenant that It is my retponsihility m notify the ecupso of the
requircmen tt/mostbemetimortuissuanceofa emfiam f0eca[amy. Signature of Applicant Date
',ohm sort=Cd asap Cur LDdr1�7 All roof coverings to be Class"B" or better
CITY OF CUPERTINO
ID'Zi-o' --C��
WATER HEATER v 3 ) 2--c--o
is CUPERTINO PERMIT APPLICATION FORM
APN # 2 S �b S Z Date: Z I D b
Building Address:
n q 5 ,5t rn a, Ave, &Veo /
Owner's Name: / hone#:
7
Contra tor: Phone: License#:
14 31 -�y11 � �lo3�o Z
Contact: Phone: Cupertino Business License#:
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Building Permit Info:
Bldg ❑ Elect ❑ Plumb (� Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: 4 ,5co Q%
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
ZQt . if
li a Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
3 z
64y. 61
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