03090021 CITY OF CUPER'fINO ,' ` %�" •'� '' ' '
BUILDING DIVISION PERMIT CONTRAGTOWINFQRMATION.l`'
BUILDING ADDRESS: HOT WATER INC PERMIT NGO 3090021
.R'S NAME` 2531 GRACELAND AVE PERMrr L$UEDATE
BECKSTROM GORDON AND NET 1,117
NE: SANITARY N0. CONTROL N0.
(650) 298-8494
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i00 LICENSED CONTRACT'OR'S DECLARATION
£U❑ I haroby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
�W with Soelion7")of Division 3 or Ne Busineu uW Professions Coot my license is
+ in lullPomo and roar
i'q_ License , 3 Lie.
3(o t 3 WATER HEATER 1NALED
f, Dam Co.MeteLAr
coe pp AR HITECTS DECRATI N 1
C K l understand my plans shall he used as public records SEP 1 20033
a.
c
o GLicensed Professional
v,IOWNER-BUILDER DECLARATION � ]�
q I hereby alarm that 1 am exempt from ftCont.aors License Law for the
BUILDING
w�/.,'riI'NG
-00 following Munn.(Section 7031.5.Business and Pmreuions Code:Any city or county
$ which myuims a permit to construct,alter,improve,demolish,or repair any structure
,Ze prior Lir its issuance.also mquires the applicant for such permit to File a signed statement
e�C Nat he is licensed pursuant to the provisions or Ne Contractor's License Taw(Chapter 9 Sq. Ft. Floor Area Valuation
2 (commencing With Section 7")of Division 3 of the Business and Professions Cade)or
that he Is exempt Nemfrom and the buts far due alleged ettmpdon.Any violation of
Section 7031.5 by any applicant fors permit subjects the applicant to.Civil penalty of APN Number. Occupancy Type
not mole Nan live hundred doll,.(55130). - — -- - —
❑ I,ea owner of the property,or my omployces with wages As their sole compensation, 'T
will do the work,and thesracturn is not intended or offered for sale(Sec.Trials,Business 502 - FINAL
and Pmfessims Code:The Contractors License law Jars not apply to an owner or r
pmpeny,who builds or improves themon.and who doessuch work himselfor through his 506 — GAS TEST
own employees.prodded ton such improvements are not intended oroRemd for sale.If. 507 — FINAL PLUMBING
however,Ne building or impmwment is said within one you of completion,Ne owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of the property,em exclusively convecting with licensed contractors to - -
construct Ne project(Sec.]Ods,Basin. Ad Profwions Cade:)The CMdusic m's Li.
cerise law docs not apply man owner of proper who builds or improves Oman.end
who contracts for such pmjecu with a contramer(s)licensed pu.uam to the Connors
License LBW.
❑1am exempt under Sec. B At P C for this mason
r Data
WORKER'S COMPENSATION DECLARATION
rm _
I hereby affiunder penalty of perjury one of the fallowing dedarstiorto
I have and will maintain a Ccnlfcom of Consort a selGiawns far Workers Compere ..
ration,es provided for by Section 37W of the labor Code,far the perfmmance of the
work For which this permit is issued.
1 haw and will mainum Worker's Compensation Inmrsnce,a mquimd by Section -
3]00o(the labor Code.for the performance of the work for which this permit is issued.
My WorkersC palmation Insurance carrier and Policy n��sma.A�s .a.rty�: //�� J
Carrier: a.J� /AT� Policy Na.:)3 Fs
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Q1d&seed.need not be completed Ethe permit is rare.handled dollar(SIM)
or less.)
I coldly that in the performance or the work for which this permit is issued.I shall not
employ any person in any manners az to become subject to the Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate of Exemption.you should
become subject to the Worker's Compensation previsions of the labor Code,you must
,Z fam.ilh comply with such provisions Cir this permit hall be deemed revoked.
OCONSTRUCTION LENDING AGENCY
I hereby tlOrm that there its construction lending agency for Performance u(
Ya > the work Far which his permit is issued(Sec.309],Civ.C.) ,
4 Q Lenders N.3.
3. z Lender's Address
C) 1 certify that 1 have read this application and state that the above AfOrudon is
y (~ concoct.1 agree to comply with all city and county ordinances and state laws relating to
7fJ building construction,and hereby authorise mprarcmatives of On city to enter upon the
C ahovcmeuioned property ror inspection purposea
ti (we)egme to taw,indemnify and keep harmless the City of Cupertino against
sn liabilities.judgments.costs and expenses which may in any way&come against aid City
J7 in consequence or the graming of this permit. b
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO POINT Issued by:S4t(2� Date
SOURCE REppClitp�10
D.m
U Re-roofs
gnuurc of AlicaHAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ur fumm building Occupant nom or handle hevrduus material
u defined by the Cupertino Municipal Code,Chapter 9.13.and the I calth and.Safety
.
Settle.355334)? All roofs shall be inspected prior to any roofing material being installed.
ED Y. Dwrl�
Will the applicant or futumbuilding occupam use equipment ordcvica which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants As dcfned by the Bay Area Air Gaudily Management all new materials for inspection.
District?
❑Yes N*--"' .
1havemWNe Mua wsmamrialsmquircmenmunder Chapur6.95oftheCalifor-
niaHcalN6SafclyCo .Scotium355O5.25533and35534,1umk.tand Nuifdo building
docs not currently how a mnanL Nat it is my rapmssihility in notify the Occupant or the .
requiremcntsw ' ustbemet dortOissusnceofaOcnihcawof cop coy Signature of Applicant Date
ler,Lir amhorred agcn Oa 6 03 All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER
�CUPEkTINO PERMIT APPLICATION FORM
APN # 2 � � /� � � Date:
Building Address���s�
Owner's Name: J Phone
) L
Contractor: Phone: License #:
Z --9Yg b3 6 ) Z
Contact: Pho • Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential PJ Commercial ❑
Cost of Project:
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A i ble Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING