03120070 CITY OF CUPERTINO - �'" ��"^s a` `"'
BUILDING DIVISION .PERMIT =-- 1 CO RACTbRANktO .-
j BUILDING ADDRESS: PERMIT NO.
HOT WATER INC 03120070
OW NEWS NAME: FSRMIT ISSUEDATE
CARQL QQNG PITr,
SANITARY7-17
OL NO.
ONE:
Ifaus
CHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCOMRACTOWSDECLARATIONlob Description
I hemby affirmthat 1 am livened under previsions of Chapter 9(commencingth Section 7")of Di ision 3 of the Business'anntd/Pro(esalons Code,and my license is
to ull force en ,f(pt v t(, Lic REPLACE WATER HEATER
ca Ct ContractorDELL c
e'3ev
ARCHITECTS DECLAR ION ■ INA ® NE®
Y n canJm ens shall useda public records e��ly`
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3�7
Licensed
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I
OWNER- URDERDECLARATION JAN 13 2004
<� 1 hereby aRrse that 1 am exempt from the Contractor's License Law for the
p O fallowing reason.(Section 71131.5.Business and Professions Code:Any city or county
$ which require a Permit to cr ndem ,alter.improve,demolish.or repair any stiocf tie
F !'' poor to its issuance,also mquim the applicant for such permit to file a signed statement
dotheisllanacdpunuantlothcpmvisions of the Contractor's Liccom Law(Chapter 9 Sq.Ft. Floor Area luat'
ti'k'e (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
.. that he is exempt tWrefmm and the basis for de alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 help 0 Occupancy Type
not more then fpm hundred dollen($501B,
0 1,as owner of the property,or my employees with wages a their wle compensation,
will do the.,it.and the structure is not intended or offered Immle(Sec.704/.Business
and Pmirssiont Cc&:The Commences License Law does not apply to an owner of Required Inspections
properywhe buildsorimproves therson.andwhodoessu In work hineselfor through his
own employees,provided thatsuch improvements are not imanded moffemd fmsele.IL
however.the building or improvement is sold within one year of completion,the owned
builder will hem the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1,as Owner of the praised,am exclusively contracting with licensed convectors to
construct this project(Sec.7044,Business and Pmfoundoes Code:)The Com timer's Li.
teas,law dors nut apply in am owner of property who Wilda or improv them..,and
who convects for such pmjecu with a convacwrts)licensed pursuant in the Commctors
Lk-
nm Law.
❑IameaempfundOSec. ,B&PCforthismeson
Owner Gain-
WORKERS
ateWORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following declarations:
1 ham and will muntain a Carol of Consent to self-insure for Workers Connotes-
saline.
omperesaline,a provided for by Section 3700 of the told,Code,for the performance Of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Intersect,as required by Section
3700 of Ne Labor Code,for the penormance of the work for which this permit is Issued.
My Worker'g.ropersentimi he=paticcantersedPolicynumbera.-
Cartier. Policy L.541�� 3 s'/to
CERTIFICATE EXEMPTION OF X PI7INN FRORO M WORKERS'
COMPENSATION INSURANCE
(Mosacction moil not W completed Ifthe permit is Intent,hundreddollan($100)
or Ica..)
I modify that in the performance of the work for which this permit is issued.I shall not
employ any former in my manner an as he become subject to the Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Condition,of Exemption,you should
become subject to the Workab Compensation provisions of the Labor Code•you must
,J Q forthwith comply with such provisions or this permit shall he deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby effort that Wert is a construction lending agency for the performance of
!Yi> Jm work(m which this permit is menace(Sec.3099.Civ.C.)
W Q Lenders Name
Z Lenders Address
I;J I canify that I ham read this application and sen,that the above information is
W Fcopeck I agues to comply with all city and county outhouses and scale laws relating to
0 U Wilding construction.itureand hereby sethorimrepmaenuuv of this city teenn,r upon the /
(W shows-(We)a cd to sm for inspection purposes
C (Wt,)agree to sem,indemnify and keep harmless the City of against against /
yy incoides,judgmcnte Spewing expenses which may in seywayseem[egainstmid City
r7
V in consequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE N
t Z (dO Re-roofs
SignatumofApplicanUConvaetor ` Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwre Wilding Occupant now or handle ha ori materiel
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532([)? �� All roofs shall be inspected prior to any roofing material being installed.
❑Ynt y ray
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit to wordous air contaminants as defined by Ne Bay Arca Air Quality Management all new materials for inspection.
Dlnrict7 / -
s( ❑Yes o
1 have mad the Weardous materials requirements under Chapter 6.95 of the califor-
meHealth&SafctyCotic,Sec acm.25505,35533 and 8534.1 understand thntfilm building -
does Out cunentiy Karo a tenant.that it is my ma crechility to silly the occupant of the
require `It RWmelposew anccofaCertifetty upacy. Signature of Applicant Date
t� , �� ( z��3 All roof coverings to be Class"B"or better
Owner or aulhanwsd 7g—em Dae
1
CITY OF CUPERTINO Z� O
j � WATER HEATER o 3 /
CiTY OF
CUPERTINO PERMIT APPLICATION FORM
APN# 35(o r5 025 Date: Z J0 D3
Building Address:
BW u-alc Qo Vti 6rhloo C - 9601 q
Owner's Name: Phone #:
—
Contractor: Phone: License
1-7- h 5o --(,,7 i- #7173G/,q?--
Contact: Phone: Cupertino Business License #:
a
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: k"G PQM Lt,GI�PX �
Residential Commercial ❑
Cost of Project: dab
. Strapped ❑ On Platform ❑ B nded ❑
New Location ❑ Replacement
Qty 'f
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