03100072 .CITY OF CUPERTINO mu _ "' �' -
BUILDING DIVISION PIJRMIT CONTRACTOR INFORMATIONe+
NUILDINGADDRESS: HOT WATER INC PERMIT No.03100072
OWNER'S NAME: 2531 GRACELAND AVE FERNUT ISSUE DATE
)NE: SANITARY CONTROL NO.
(650) 298-8494
ARCHItECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.00 LICENSED CONTRACTOR'S DECLARATION JobDescri [ion
I F 1 hereby affirm that I am licensed under previsions of Chapter 9(commencing P
with Section]OIMgn(DiAtion Sof NC Buamersand Professions Com.end my license is
in full lose ontl eft
POii Llmorechum Lie. WATER HEATER REPLACEMENT
J am
DCUmncbr
Iq- ARCHITECTS DECLARATION
1 understand my plans shall W used as public mmrds
lyU
0 Licensed Professional
OWNER-exempt frDECLARATION
0 0 I hereby moo affirm on 11. exempt from tha Comnnah,:Any c Law for the
p00 following moon.Permit
Rome=[,aim.hop Pmfac inth Co dc:Any city structure
1$ which require a permit account
t e,alter.impreve,h Permit t m repair ed internal poor m its issuance.pursuant atm to to IM applicant for Metech toms'm filo s Signed natemcm
.ZQ (commhot he incingsedction7 7")
sO of
and
Profession
(Chapter Sq. Ft.Floor Area Valuation
$ (cat be is xem it therefrom
Rand)of limit farn 3 of the Business pt on.Any
vi Qxlc)m y�
Nn he is exempt NcmOom and the buil for Ne alleged exemption.Any vlNouon of ��
Section 7031.5 by any applicant for a pan[, Ne applicant to a civil penally of -' APN Number Occupancy Type
not more Nan five hundred dollars($300).
I,a owner of the property,or my employees with wages as their Sole compensation, ✓ /
will do the work,and the Structure is nor handled oroRered fo...e(Stt.701a,Businev 50 FINAL&M1iARc"J�RGY
and Professions Cade:The Con omemes Liame law does not apply to an owner or
property who builds orimprows Memon,and who doessuch work himselforthrough his 5 .S!T
own employae,provided that such Improvement art not intended orofferril formic.If. SO W — FINA'L� P�IIJMBING
SOW—
however,Neavetebding rimprowmenng sold Met
withinamyear of completion,Na owner- \�
bollen will have the burden of proving Not he did not build m improve for purpossMe own of
r.
ale J.
❑1,as owner of the properly,am exclusively contracting with licened contactors to
contract the pumper(Sec.7044.Business and Profesdom Code:)The Contracmri Li.
cense Law Coca not apply to an owner of property who Guilds or implant thereon,and
who contracts for such projecta with a camrscmr(s)licensed partition to Ne ConuacmM1 \
License Law.
❑I etas,exempt under Sec. .B&P C(or This reason
Owner Dale
WORKER'S COMPENSATION DECLARATION /
1 homey&Man under penally of perjury one of the following declaration:
I haw and will malmain a Certificate ofConsenl to self iusum for Workers Compere
carton.a provided for by Section 3700 of Ne Labor Coda,for Ne performance of the
work for which this permit is issued.
haw and will maintain Worker's Compensation Inurana,ss required by Section
700 of tbe Iabm Code,for the performance of Ne work for which this permit is issued.
My WorkefyG_1A
mpensadon lncrsna artier and Poliq num�e O
Carries'�� / A T.Q Poliry No.: /3 f�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need notbecomplmod IfIbe Irrmit is formse hundred dollars(SIM)
or it.)
1 certify Nat in the performance of Ne work for which this permit 0 issued.I shall not
employ any retch in any manner an as an become Subject to the Worteri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of Ne Labor Codc,you must
O forthwith comply with such provision or this permit Nall be deemed ranked.
CONSTRUCTION LENDING AGENCY
I hereby aRrm that More is combustion lending agency for the performance of
the work for which lhls permit Is issued(See.3097,Ci,C.)
Q Lender's Name
z Lendcr'a Address
J Q 1«Airy that I low read this application and some Nn the above information it
y tortect l agree to comply with all city and county ondinmas and Stam laws milting as
�U building convection,and hereby authoom mprasematiaa of Nis city to cool upon the
W 'ban-mentioned pmNrty for intention purposes.
'r G (We)agree to Saw,indemnify and keep harmless the City Of Cupertino against
h liabilities,judgments,costs and expenses which may in any way accmc against said City
JZ in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by:9 � Date
SOURCE 1 TIO �� �/Tr P16910
:insure dsam
clhr (. /Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building Occupant Store or handle haerduus material
asdelncd by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
cwk,SeNnh 2ss31a>7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Ye 12 No P P Y B g
Will the applicant or future building occupant use aquipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it reactions air cnnmminants as Ccfncd by the Bay Arca Ail Quality Managcmanl all new materials for inspection.
istrin? ,['
❑Yes LyNo
I lament Me Wnmhusmateriah requimmenu under Chapter 6.Y5 ofNe Califory
nu He lth&SafeyCodc.Swd=25505.25533md2S534.lundcntmdthmiftbe Wilding
doe not curan0y haw a tenant.Nn it u my mspomihility,to notify Ibe mcupml of the
mqulmmcnWvM mull W mttpnor to issumcc are CeNfcau;of cup Signature of Applicant Date
//�/ must I��d 71 b� All roof coverings to be Class "B"or better
Owncroraixtrroorirediligcm r m g
A
CITY OF CUPERTINO
WATER HEATER
b b a � �
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: a--) S 0`
Owner's Name: P e #:
Contractor one: License#:
`JL �C�/Z
Contact: Ph ne: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb A97 Mech ❑
Job Description: /
Residential j2 Commercial ❑
Cost of Project: a3—
Strapped
-Strapped On Platform 11 Bonded
New Location ElReplacement
Qty. if
A lica Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2, t_
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