03080120CITY OF CUPERTINO-'
-
BUILDING DlvlsloN PERMITCONTRACTOR
INT.ORMATIONv4_
88ULDING ADDRESS:
JOANNE POGGI
PERMIT "03080120
OWNER' NAME.-
PERMIT ISSUE DATE
ONE:
SANITARY 030. CONTROL NO.
ARCHITECVENGINEER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I
JOU Description
1 hereby affirm that 1 am licensed under row pons of Chapter 9 (Commencing
p
with Section 7000) Of Division 3.f the Busine a and Profession, Code, and my license is
in full force and effect.
Littmc Chis ue.e
REPLACE WATER HEATER m
jM
Data Commit.,
µ°E tea
B
ARCHITECTS DECLARATION
, .ma
I understand my plans ahali he hard as public records
AUG 2 5 2003
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
�V Ifly rypAg�
construct, alter, demolish, or repair any structure
Which requires a pmmit m improve,
LDI 1t
prior to its issuance, also requires the applicant for such Permit to file a signed statement
Sq. FC Floor Area
Valuation
that he is licensed pursuant to the provisions of the Comnmor's License Law (Chapter 9
(commencing with Scotian 701 of Division 3 of the Business and Professions Cale) or
Nat he is exempt ocmfrom and the basis for the alleged exemption. Any viniati'f of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit Subjects the applicant o a civil Penally of
not more than five hundred dollars (5500).
❑ 1, a owner of the property, or my employees with wages as their snit compensation,
SO2 — FINAL I p
QJAJR RGY
will do to work. and the aRucmn is not intended or offered for sale (Sec. 7W, Business
License
and Professions Code: The Contractors law does not apply to an owner of
tUj _
property who builds or improves thereon. and who does such work himaclfor through his
506 - GAS TES
own employees, provided that such improvements are not intenad sur offered for .]A. IL
SO7 — FINAL PLUMBING
however, the building or improvement is sold within one year of completion. Ne owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed convenors to
construct the project (Sec. 7044, Business and Professions Code:) The Con4acmrY Li.
-
cense Law does not apply to an Owner of property who builds or improves memon, and
who contracts for such projects with a contractors) licensed pursuant m the Contractors
rase ave,
A exempt antler Sec. _ B & P C f toss on
her
WORKER'S CO EN T N DECIARATI@N
YVI bore y e ren under Penally of one of the following declarations:
Ihaws and aintain a Cenifcam of Consent to self-insure for Worker's Compen-
>
smfor. as provided for by Section 3700 of the Lehr Code, for the performance of the
work for which Iia permit is issued. '
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3]W of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insunmea carrier and Policy number am:
Cartier: ' Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the permit is intone hundred dollars ($100)
or less.
I crnify Nat in the performance of the work for which this Permit is issued, I shall not
employ any person in any manner sa as to become subject to the Workers' Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If, alter making this Ccrif icate of Exemption, you should
become subject to the Worker'a Compensation provisions of the Labor Code, you must
fmthwin comply with such provisions or this permit shall he deemed revoked. .
CONSTRUCTION LENDING AGENCY
I hereby affirm Ian there is a construction lending agency Int the performance of
oc work for which this permit is issued li c 3097, Civ. C.1
Lender's Name
Lenders Address
1 cagme that I have rend this ti and stain that the above information is
building 1 sgme y and coon
comply with all city end county ordinances and sole laws relating
of e
a ion, and hereby authon representatives of this city m enter upon the
building end
shove-me imcd
)anre property for inspection purposes.
F
(We)hay nics,in
(Wc)sgmet,save, indemnifyexpenses which
the City of against id Cagaity
cosh and expenses which may in any way accme against said City
in of the grantingTAN Of this permit.
consurqu race of the
A
/>
APPLICANT
APPLICANT UNOERST D WILL COMPLY WITH LL N N-POINT
Issued by: Date
SOURCE REGULATION S. (Q
Re-roofs (
Type Of Roof
O o
9
store pplican✓Comnctor_21ek
HAZARDOUS RIALS DISCLOSUR
W11 apPfc.mor future bu mg occupant store or handle haziumus mucrial
as defined the Cupertino Municipal Code, Chapter 9.12, and the Health antl Safety
Code, Section 25532(a)?
❑Yes )its
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 building occupant use equipment or devices which
it harardnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
istrict7
❑Yes *a,
I have mad the hurallous materials requirtmcnm under Chapter 6.95 of we Califor-
nia Health & Safety Code, Sections 25505,25533 and 25534. [understand thaif od building
dues not cmocritly have a ren i fit my respomihility to madly me occupant of the
Rquimments which most be mm t kwaechfa Cenlfica 'Ese ancy.
Signature of Applicant Dale
OF
nozom
All roof coverings to be Class "B" or better
suer u a hmived agem
ate
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
AUG a 2 2003
Contractor
Address/City. Phone #
State License #
Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property,Owner's Signature: Date: 8oal 03
Job Address: aD�00 Qqwu OOL L61A Permit # ® O g
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
5,41
CITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
APN # 3
;7 _ 0/6
Date:
Date:
�'laa p3
Building Address:
;a10 stlycr CaK Line.
Plumbing Permit Issuance
Owner's Name:
BENERGY
Phone #:
yob 3y3-39�(
BUILDING
cyan e_ f� 1
Business License
Contractor:gs
Phone:
�I�mwl�n
License #:
Contact:
Mar-
Phone:
�hnsrm
Cupertino Business License #:
Building Permit Info:
Bldg ❑
Elect ❑ Plumb Ole"
Mech ❑
Job Description:
Residential 1�
Commercial ❑
Cost of Project:
-7Q
Strapped ❑
On Platform ❑ Bonded ❑
New Location ❑
Replacement
Qty. if
Aanlicable Fee ID
Fee Descrintion
Fee Groun
BPWHEATER
Water Heater / Vent.
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
-4 22-3
6Y,61