03070125 CITY OF CUPERTINO :h , Inwn :t r ,�
' BUILDING DIVISION PERMIT ONT,"OT,ORINFO MATIO
au ILDING ADDRESS: BRAND KITCHENS & DESIGN PERMIT NO 03070125
N ' NAME: QBbilG 13715 QUITO RD PERMIT lsslfe DATE
NE: SANITARY O. CONTROL N0.
(408) 871-8190
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300 LICENSED CONTRACTOR'S DECLARATION ]Ob Description
u 1 Mrchy&MOm that 1 am licemsa under provisions of Chapter 9(commencing
�E withs.qanpAM))nI'Division 3 of Ne Business Professions Code,and my license is CC
=c mmur aggaa erroer, gimme �rj�f NEW WATER HEATER (RELOCATIVOINALG®
jr�? Llce a Lic.X
ARCHITELTE DE A 3 1 2003
i U 1 um
ndcenJ my plans abaft W used as public recnrda JUL
O� Licensed Professional
S OWNER-BUILDER DECLARATION
p 1 hereby affirm that I am exempt from the Contractor's License Law for the 931119 INN
i O O following mum.(Section 1031.5,Business and Professions Cole:Any lily or.Only aw
$E� which requires•Permit to construct,alter,improve,demolish,or mpair any structure
Hsi prior to its issuance,Also requires the applicant for such Permit o file a signed statement
< that he is licensed pursuant nthe previsions ofthe Comracmr'sLircnuUw(Chapter 9 Sq. Ft. Floor Area Valuation
se (commencing with section 7100)of Division 3 of the Business and Processions Coac)nr
le that he is exempt therefrom and the buss for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a Permit subjects the Applicant to.civil Penalty of APN Number Occupancy Type
not mom than fire hundred dollars(1000).
❑Luowner of the prapeny,or my smPloytts wiH wage utheir sole.mpeualion,
will do the work,and the awetum is not intended oroffered far tale(Sec.7004,Business 502 - FINAL ) &TP lap-CFA RGY
.it Professions Cods:The Conlndor's License 4w rims rot apply to an owner or
propeny who builds or impmxrs Hereon.and who dmuuch work himselfor through his 506 — GAS TES
awn employees,provided that each improvements lie not intended orolfered for sale.It. 507 — FINAL PLUMBING
however,He building or improvement is sold within mm year of.mpletian,He owner-
hullder will have the burden of proving Har he dial not Wild or improve for purpose of
ark.).
0 1,as owner of the property,am exclusively contracting with licensed contrAcmm to
construct the project(Sec.7004,Business and Professions Code:)The Contractor's Lt. -
Came law does not apply to an owner of proper who Wilds or improves themon.and
who contracts for such projects with a contacmr(U licensed pursuant o the Comomfors
License Law.
0 1 Am exempt under Sec. B&P C for this rcuon
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the following declarations:
I have and will maimain a Cenirom ofCament to self-insum for WorkeM1 Campen.
satian,u provided for by Section 3700 of Hbo
Live lar Code,for the Performance of the
work far which this permit is issued.
0 1 haus and will maintain Worker's Compensation Insuruce,u required by Section
37M of the labor Code,far the performmec of the work for which this permit is issued.
My orkeer'scoomKnss—ation Inssunnnm eauie an olicy number am:
"cr.�!—ftC f�IUr/ h No.: '.�-ll J.l
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lou¢nim need not M aarepleted If IW remit is for oro hvndmd Cnllam(Stoo)
no less.)
1 certify Har in the performance of He work for which this Permit is issued,1 shall not
employ any per.n in any manner an As to become subject to the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL alter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the LAW CMA,you mum
.JZ forthwith comply with such provisions or this permit shall he deemed revoked.
'EO heatCONSTRUCTION LENDING AGENCY Nn
y �.
.F Ihy aM. Here its construction lendingsgeacy far the perfurmantt of
O: r7 He work far which this Permit is issmd(Sec.3(97,Civ.C.)
W Q Lenders Name
Lender's Address
U Q 1 certify that 1 have read this application and some that the Above information is
It, F cancer,I agree to comply with all city and county Ordinances and state laws mlating to
Obuilding construction.and hereby authorize Mpresentarirrs of this City to Amer upon the
V
U above-mentioned Property far inspeclian purposes.
6r,
(We)ague to Cove,indemnify and keep hay in an the y me of Cogent against 7
Z in Riles,judgments,coals and ofpenseswhich may in any way eccnc against said City
U Z A consequence of RA UNDERSTANDS
lir lhis.Pcrmit.
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
;CaR.
CE REG ATIONS.
�CJ /G s• Re-roofs
naturt o! ppl occult
H ZARDOU MATERIALS DISCLOSURE ructor Date Type Of Roof
VCO
Will the applicant lir future building uccupam more or handle haysrduus material
defined by the Cupenlno Municipal CMA,Chapter 9.11,lid the Health and Safety Stenion 25532(q? / All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes ^$I Na P P Y g B
Will the applicant or future building mcupmt use cyuipmcnl or Jcvitts which
If a roof is installed without first obtaining an inspection,I agree to remove
is haxa dons air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
dict?
Dyes 'IV,No
I have mad the havard,maTTTTTmalcri amyvimmcmt unJer Chaper695 afthe CslifnP
ilia HulH&Safelycade,5ecdms25 .15533 enJ25574.1uadenthndlhm ifthe Wilding
Jos not Comm l ve a len Hal is my, aprraap lily to nMty He Occupant of the
manna Cmxw :the a noccruremeafoe.PSignature of Applicant Date
° ado'
We,araatha ,gent Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINO
WATER HEATER
CUPER INO PERMIT APPLICATION FORM
APN# � Date:
Building Address:
/OAR0 L c
Owner's Name: Phone#:
Contractor: Phone: License#:
0"1V4 / - /-8/ �r0 5oava3
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ ect ❑ H P mb Mech ❑
Job Description: /� � «�
Residential E) C' Comm cial ❑
Cost of Project: r
Strapped On Platform' Bonded
New Location Replacement E3
Qty. if
A 1' a 1 Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING