04030183 3 CITY OF CUPERTINO
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BUILDING DIION PERMIT
BUILDING ADDRESS: PERMIT NO.
a HOT WATER INC 04030183
OWNER'S NAME: SPIZiNGS DR PERMrr SSUEDATE
12
ONE: DARAJAN 0523 SANITARY OL NO.
ARCHITCCTISNOWEER: BUILDING PERMIT
BLDG ELECT PLUMB
MECH
+IpC LICENSED CONTRACTOR'S DECLARATION Job Descriptiopp1���
1 hereby affirm that 1 am licansed under provisions of Chapter 9(commencing 1� /�s LE®
Mil,Section 7")ofDivi,ion Sof the Business and Professions Code,and my license is i /Ism
^'D mmufamesMsff` Z REPLACE WATER HEATER
Slr= Licxwaoc `�3 Lie.» MAY 11 2004
Zd Date Con DEC -
AR udi W an DEC ARA et
I undcrwnJ my plans shall M1c and as puM1lic macrotia
3�u
M3� Licensed Professional BUILDING
DECLARATION
1 herchy affirm Net I em exempt from the Commutes License Law for the
S:a O following mason.(Section 70313,Business and Professions Code:Any city at county
$ which requires a permit to construct.altar,improve,demolish.or mpalr any structure
F�Hy
prior o its issuance.also mquims the applicant forsuch permit to file a signed statement
O that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuatio
� $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Nat he Is exempt Champions and the basis for the alleged connotation.Any violation of
Section 7D31.5 by my applicant for a permit subjects the applicant W a civil penalty of 3 93"4N)0Aer0 0 Occupancy Type
not mom than five hundred dolls.(ML _
❑I,as owner of the pmperty,or my employees with wages an their sets compensation,
will do dm.od,and dowucture ismaulended oroffemad foraale(Sec.7044,Bualneu
no Required Inspections
d Professions Code:The Committees n tters License Law donot apply to an Owner of q P
prep any w ho Wilds or i mpmws thereon.and who does such work himself or through his
Own employers,provided that such improvements am oat intended oro@mad for Sale. t.
however,the building or improvement is sold within one year of completion,to owner.
builder will have the burden of proving Bass he did not build or improve for purpose of
salt.).
❑1,se owner of the property,am exclusively contracting with licensed contracton to
consumer the pmject(Sec.7044,Business and professions Code:)The Contraction's LI-
ceme law den not apply to an owner of property who builds of improves thereon,and,
who convects for such prejeclo with a contractor(s)licensed pursuant W the Contractors
Lice..law,
❑l are exempt under Sec .B&PC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aBhm under penally of perjury Om of Bae fallowing declaration:
I have and will maintain a Cortificala of Consent 10 self-insure for WaxiCompen-
sation,in provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Weaker's Compensation Insurance,as inquired by Section
of the labor Code,for rhe psrformance of Ne weals far which this permit Is issued.
My Workers Compensation hommu m carrier sad Policy number am:
Cartier. Are rutin Policy No,; 6
ORKERS'
CERTIFICATE OFTXtMPr10N FROM
COMPENSATION INSURANCE
(This section road not he completed if the Permit Is faronc hundmddollw(SIM)
or less.)
I cenify that in the performance of Bac.,it fm which this permit is issued,I shell not
employ any person in any mmacr se w W become subject to the Workers Compensation
Laws of California.Dow
Applicant
NOTICE TO APPLICANT:If.after making this Cenificate of Exemption,you should
become subject W the Worker's Compensation paxvisiom of the labor Code,you must
OfoMwith comply with such provisions or this permit shell be accrued masked.
.Zi CONSTRUCTION LENDING AGENCY
[.r (hereby Dim,Nat there is a construction lending agency for the performance of
Ni 7 the work for which this permit is issued(Sec.3097,Clv.C.)
W Q Lenders Name
z leader's Address
U Q 1 certify that I have read this application and stat:that the above information is
I, correct.1 agree to comply with all city and county ordinances and slow laws misting W
0U building construction,and hereby authorm mpresematises of this city to coast upon the
W .hove-mentioned property for inspection purpong
(Wo)agree to save,indemnify and keep hmmlcu the City of Cupertino against
pj Iiibilidu,judgmenu,cosu and espemes which eery in any wey accrue against said City -
U7 in consequence of the Condo&of this permit.
r^• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL IONS. Q3J,2C//� Re-roofs
`� P 4:42
Srgnewrcaf Ap teas anuector Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant smrc or handle haeum us malarial
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
li0van,
ook.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑NO
Will Bac applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
not havardam air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
istrict?
❑Yes ON.
1 have mad the hzsardms mawrials acquirements under Chapter 6.95 of the Calikir
ia Health&Safely Code,Sections 25505.25533 and 25534.1 ndersund thaifthe building
na not currently haw a h mm,than it b my mapomobility W nodly the occupant of dm
cquiacmcn6 which mint op dal normiuuncc of a Ccnifcaas 04�u Signature of Applicant Date
T Y , l�� 3 All roof coverings to be Class "B"or better
Or whotis.od agent Dow
Community Development
0 Torre Avenue
Cupertino CA 9 014
Telephone(408)777-3228
allor Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: / ! PERMIT t�
OWNER'S NAME: >4
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing , , �wC
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
/, 0� 2
Contractor Signature Date
LI CITY OF CUPERTINO
WATER HEATER d 62 o/F-3
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
3&0 - 5L[ -o03 q/ o
Building Address:
If `Sle Va..h
Owner' Name:Phon #:
Aa sr cL c(4 ra ,0 v�
o b' a5 3- 1 S SS
Contractor: HOT WATER, I Phone: (oho — cense#: J a
.963 INDUSTRIAL ROAD UNIT D
Contact: SAN CARLOS,CALIFORNIA 94070 Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb LY Mech ❑
Job Description: WCs--Y er
Residential Commercial ❑
Cost of Project:
5d d d/
Strapped U On Platform Bonded
• New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business License BUILDING