04030142CITY OFCUPERTINO
BUILDING DIVISION PERMIT
;°aCONTRACTORINFORMATION•"
BUILDING ADDRESS:
WATER HEATERS ONLY
PERMIT "04030142
OWNER'S NAME:
PERMITL'SSUBDATE
FAY CHONG
ONE:
SANITARY NO. CONTROL NO.
(800)835-5946
ARCHITECTMNGINEER:
BUILDINO PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I hereby that 1 em limned under provisions of Charter 9 (commc=ing
lob Descr A ■
ED
7=))orDivision 3 o the Business read Profcuinm Cade,end mylicense is
wida Section )) or
G
In no affect.
REPLACE WATER HEATER
s
License Class
Data ""` Li "
Data C'S
MAR 1 9 2004
DEC
ARCat[beue DECLARATION
I underaunJ my Plans shall he used as public recnrN
BUILDING
Licensed Profcsaional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
j following recon. (Section 7031.5. Business and Profentinm Code: Any city or county
which requires a Permit to Contract. altar. 1,11prove, demolish, or minor my structure
prior N its ismance. also requiter the applicant for such pemnl to rite a signed statement
mat he in licensed pursuant to me pmvitmm of the cnnlmamra U.. Law (Ch.ptw9
Sq. Ft. Floor Area Valuation
(commencing with Section ]OW) of Division 3 of me Business and Professions Csxle) or
mu he is exempt therefrom and use basis in, the alleged a=mption. Any violation of
Section 7031.5 by cry applicant fora permit subjects me applicant to a civil penalty of
3 294144II-Mcro 0
Oe
Occupancy Y EYP
not more man five hundred dollen ($5110).
0 L u owner of the property, ormy employm wire wapars (heir vele compensation,
will da me work and IheslNCwre u not intended cad@rad forme (Sec. ]fits, Buri».•
Required Inspections
and Profeadans Code: The Chanteuses Liam law dm not apply m an owner of
property who bulldsor Imprmes mrehn,andwhd dassuch work himselfor through his
'
own employees, provided that such improvements as not Intanded aoRead forme. IL
however, the building or improvement is said within on year of completion, the owner -
builder will have W burden of proving that he did not Wild or Improve for purpose of
sale J.
war or The pmpeny, am exclusively contracting with lianaed mntocrors to
"caR{IrIKI me project (Sec. 7W. Business and Professions Colo) The Conlrawhrl U.
cense Law dm not apply to an caner of property who Wilds or improves daemon, and
who contracts for such projects with a conractor(s) licensed pure ant to the Contractors
License Law.
❑ I am exe�mpl underSc�c. . B & P C for Ih. moon
/
' c,—Q- eti D.ta 3//s/
WORKER'S COMPENSAnt.mi DECLARATION
I hereby affirm under party of perjury am of me following dalaruiav:
I haw and will momism a Certificate ofcnnsem to alGiasure for worker's Compen.
mim.. as provided for by Section 3700 of me Labor Code, for the perlormmm of the
work for which this permit is Issued.
El 1 haw and will maintain Wmkees Compensation Insurance, m required by Section
3700 of me labor Code. for the performance of the work for which this permit is luund.
My Workers Compensation lesonnce carrier end Polity number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin section sed notbecompleted time permit Is into= hundred dollars (SIM)
or leas.)
I cattily mm in me performance of the work fa which this rermll in intend. I shall not
employ any person in any mmncr an as at become subject to the Warken' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Centftcatc of Exemption, you should
become subject to the Worker's Compem0un provisions of the Labor Code, you must
faMwim comply with such provisions or this Permit mail he decmod revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that mea is a construction lending agency for me performance of
the work for which thin permit is issued (Sec. 3097. Civ. C.)
Lender's Namc
Lank r9 Address
1 cenifY that I haw and this application and sus that the .how information is
conam I agree to comply wit at city and county ordinances and aux laws relating to
building construction, and hereby amhodm representatives of this city to crow upon me
.lave -mentioned property for inspection Purposes.
(We) egme to cost, and expen and keep hay in an the City of Cupertino s ageism
liabilities, judgments, tatoand $which they in any ways<enta ageinal said City
TJ
of daegranting of this permit.
Of this
A PLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
I/ O
Issued by: Dale
SOURS: REGULATIONS.
3//1-10y
f�
Re -roofs
Type of Roof
S'atureof ApplicantlCommetor ta
HAZARDOUS MATERIALS DISCLOSURE
WalthCepplinnlorfulure Wildingmcupmislomorhandlehv ousmatarial
as defined by the Cupertino Municipal Coda. Chapter 9.11. and the Health and Safety
Sc as3z(.>?
❑y. ON.
Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding ammpant me awipmem or devices which
mil harmd"us air contaminants as donned by the Bay Area Air Quality Management
all new materials for inspection.
District? ��//
❑Yes IONo
I haw mad the heraNuusmatcrials requirements under Chapter6.95 of the Califon
ria Hamm&SafelyCodc,Secd.25505.1i533 and 25534.1 undersuM Ihattfdx Wilding
dm nut currently bew a tamart. that it in my responsibility w nudity tie ..w, or she
require m nu which must bemctptiormintmnceofa Ccoinmmof Ocm,Pancy.
/,$—
Signature of Applicant Date
cle-3
All roof coverings to be Class "B" or better
Ower or rived agent Data
Its
CITY OF
UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRE :
905"70 S�('VOy U/1 /c c.N
PERMIT # U�
J
OWNEXSNAM}d/ Pli-v cc-tdkc
P NE# �/og yyb_os�
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner./§ Signature Date
--
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner./§ Signature Date
--
�YO
CITY of
CUPERTINO
CITY OF CUPERTINO v 3 o 1�12—
WATER HEATER
PERMIT APPLICATION FORM
APN #3 23 �1 12
BPWHEATER
Water Heater / Vent
Date:
Building Address:
Plumbing Permit Issuance
PLUMBING
a 05-90 C,-YH-0Y on
Energy
BUILDING
Owner's Name:
Business License
BUILDING
Phone #:
F-,4C(-loqc,
0e 'fY -DrO
Contractor:
Phone:
License #:
WAt�IL K� it rL�1 O•J�y ,w C
/ X00 --5-9Y&
3 74S —7 3
Contact:
Phone:
Cupertino Business License #:
Building Permit Info:
Bldg Elect ❑
b
19 Mech ❑
Job D scription:
12 I Pp 9 C - U 6-rc
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Residential
Commercial ❑
Cost of P
4 92 `7
Strapp On Platform ❑
Bonded
❑
New Location Re laceme
Aoplic6bk) Fee ID
Fee Description
Fee Group
t
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
t