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06010026"i—,CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR�INF9�ORMATION ., > ltd �"'zi�i.-F �.,, �- �xY '3:.' BUILDINGADDRESS: 2664 c;TT.VFR OAK T.N WATER HEATERS ONLY PP"MTTNO'06010026 OWNER'S NAME: PERMTT ISSUE DATE LORI POW 970 E. MAIN ST 01/05/2006 NE: SANITARY NO, CONTROL NO. (800)835-5946 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MOCK LICENSED CONTRACT'OR'S DECLARATION Job Description 1 hcmby affirm that 1 am licensed undo provision of Chapxr 9 (commcming P with Ecefiam? ).fDivielon]ofthe BusxaMPmfcssims Caan m imMy license is infnBnx mrooa derfeq�� 3(o REPLACE WATER HEATER Liccm CIaMZ-� Lie. N De��O V ARCHITECT ECLARATION �t S']�1 J ! I unMrstand my plan: shag W useJ as Public mcmds ������� Licensed Professional OatNE. BUILDER DECLARATION I hamby .(firm that 1 License Law far the exempt caro the Canins ' Co following anon. (Section J(IJ L5, Business and Professions Calc: Any city or county 1. c which requires a Permit to c.nswcL alcor. improve, dcmoliN, or mica any structure I I!y nP7 unr $800 prior to, its issuance, also requires the applicant for Such Permit l0 file a signed statement that he is littnud pursuant to the provisions of the Commaclofs License Law (Chapmr9 Sq. Ft. F oor Area Valuation (commencing with Section ]Doo) of Division J of the Business and Professions Crile) or that M u exempt therefrom and the basis for the alleged exmption. Any violation of IN All rsalk flogi Section 7031.5 by any applioat for a permit subjects the applicant to e civil parlay of Occupancy Type not mom than fw hundred dollars (s5W). P Y YP ❑ 1, as; owner of the property, or my employees with wages as their sale compensation, will M Bre work, and the auumut, is not intended or offered for Who (Sm. ]OSA, Business and Professions Code: The Contractor's Limese law dose not apply to an owner of Required Inspections properly who builds., improves thereon, and who dousmhwork himself., through hu Own cenpl.yms, provided that such improvements art not intended onoffved for sale, if. howewq the building or improvement is mid within one year of completion. the owner, builder will haw the burden of proving that W did not Wild or improve fm purpose of sale.). ❑ 1. as owner of Ne propeny, am exclusively contracting with littnsed convectors to coastmct the pmjeci (Sec. ]BSA, Business and Professions Cale:) M Contr.ctur's Li- ccnse law does not apply to in owner of prepeny.who Wilds or impmws thereon, and who contracts for such projects with aeontractor(s) licensed pursuant an the Contraspots , License taw, ❑ I am exempt under See. ,B&PC for this moan Owner Dam WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury, am of the following declarations: T ban and will maintain aCCNficam of Consent to mlf-insure for Worker'sCompen- ion, as provided for by Section 37W of dm Labor Code, for the performance of the k for which this Permit is issued. Ir I ban and will maintain Workces Compensation Insurance, as required by Section W of the labor Code. for Ne perf.munx of the work far which this Permit is issued. Work Compc ufLLy�n-llnn outc ej aana{PPoolicyo��+rtia !nR �'Po1ie Na.: `1 CE gCAM OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Dissection need not bo completed if far permit isforane huedlM Mlles (SIM) nr less) I unify that in the pe,fam town of the work for which this permit is issued. I shall ata employ any reason in any mannerst, as to Wcome mbjauo the Workcri Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making this CenlOcam of Exemption, you should become Subject to the Worker's Compensation provisions of the labor Code, you most foMwith comply with such Provisions or this Permit shall W daemon mokcd. CONSTRUCTION LENDING AGENCY 1 hcmby affirm that then is a cormsWnien lending gmxy fa the perfunnnme of One work ter which this permit is issued (Sae. 3097, Civ, C.) Under' Name Lender's AMS.. I codify that I ban mad this application and stem that the anon inamoda. is comecL I agree to comply with all city W county omm noes and state laws miming to Wilding eonsvuction, and hereby Ruthann mpmsentatiwe of this city to enter upon the abovemenuunedpmPct for i expenses purposes. Wo) agree to an, indemnify and keep harmless the City of Cupertino against liebiliuu,judgmcnts, cots W cxpcsmacs which may In any way attmc against said City in eonsegucnce o the Granting of th t. 'PLICA APPLICANT DERST WILL PLY WITH ALL NON- INT Issued sou by: Date Re-roofs I/6 &gnawm of ApphcanVC.nuaclor �— a HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant mom or handle hwardous material u CIS d by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety otic. Salla 255J3 ❑ Yes N. (a)? All roofs shall be inspected prior to any roofing material being installed. Will the applicant or (sever building =open( sex equipment or devices which If a roof is installed without first obtaining agree to remove an inspection, I P it haxardnus air contmninantr H unfired by the Bay Amo Air Quality Management all new materials for inspection. isuicn ❑Yes 0N 1 have mad the hvardonsnt-led-1 myuiremcns under Chapmr6.95 of dm Califoo- nil Health&Safety Code, Sections 35505, 25533 W 255M. I undersell thm if use Wilding Ioes not c 11, bac a mnanl t ismy ter nobility tonotify the aeupant of the mquimmc hmhmaa rtoissu of acomficamora.n era Signature of Applicant Date All roof coverings to be Class "B" or better 0.6tomom.ri.d.gent i' Dam • it CJ a L A e.a.Yh. 0,4. JQ� Owner/ Contractor Signature Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS:,', Co `f `a tit � c e.. ©� Ze, PERMIT # 06c�i vv Z L OWNER'S NAME: ow PHONE # ZS 5-c-Fggg GENERAL CONTRACTOR 4 FAX # I am not using any subcontractors -a& l ea L Ovt4 Signature Date Please check applicable subcontractors and complete the following informatinn lSo-4 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 lSo-4 Date t 0 t S CITY OF CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM APN # z 6113 BUILDING Date: �/ L Building Address: z z ���{ b�c� J BENERGY Energy Owner's Name: o't-iJ vw BUSLIC Phone #: 25.5 Contractor Pho e:g -g to FOO -3 b 7 Y5 7OA Contact: hone: J Cupertino Bxsiyp�L icense #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: a.tc� Residential Commercial ❑ Cost of Project: �\ • vV Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Qty. if ADnlicable Fee M Far lircrri Minn FPP (:rnnn 1 BPWHEATER Water Heater / Vent BUILDING ! PPERMITFEE Plumbing Permit Issuance PLUMBING J BENERGY Energy BUILDING BUSLIC Business License BUILDING