04080179 CITY OF CUPERTINO z y. TM //�� �y*sLL �ary!� ��� rT
BUILDING DIVISION PERMIT s � NTUXGTjl7R I,NFb�tV ATidNi
BUILDINGADDRESS: WATER HEATERS ONLY PERMIT No.04080179
OWNER'S NAME: PERMIT ISSUE DAM
RU11TH RTCR 970 17. MAIN ST, SUITE 2
ONE: SANITARY N CONTROL NO.
ARCHI7ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o M LICENSED CONTRACTORS DECLARATION '���
Z I hereby affirm that I em liunud antler previsions of Chapter 9(commencing lob Descrip E
n< with Section 7")ofDiA.ion Sof Ne Business and Professions Code.and my license is
< in full fore*and t.
5a LkenrcF.yLk.g 37ti5 73 REPLACE WATER HEATER
❑ Dem "J Canhoomr-
mmARCHI'IELTS DECLARATION *1004
I unanJ my plans shell be used as public ards SEP L
JWU
wQ Licensed Professional BUILDING I ®I
S OWNER-BUILDER DECLARATION ■�aY[7 N^
I heathy affirm Nm 1 1. ,exempt from the Convector's Uecnu Law for Ibe (`vim—J
T.e o fallowing reason.(Section](131.5,Business and not.de o i Code:Any city as county
q which requires a permit m construct,*iter.improve,ticmolkh,or repair any atmcture
H < poor to its issuance.also requires the applicant for tach permit o file a signed statement
Ihat he is licensed pursuant to the Provisions of Me Commuleri License Law(Chapter 9 Sq.Ft.Floor Area Valuation
¢ $ (commencing with Section7")of Division 3 of Ne Business and Profession Code)or
But he is exempt therefrom and the bask for the alleged exemption.Any violation of *,,-
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3� Q]1�tfFs Q Occupancy e
nos teas*Nan five hundred dollar(5300). P y TyP
❑6asowmr .,oul pmpeny,me i.maimoyoes wlNored festhel(ec.c ,Business
will Pr Newark and e:no Cor ea tottotenmd aro w do(anal*(Sec.7004,owner of
and Professions Code:The Co Memory ndwho Law dors not apply lf an owner of Required IDSpeCIIODS
Property wyeesho ,provided
ireptoves thereon,vedwho da,nothoonded imulfaal Waugh his
awnemployees,ping or thatavemimprovementsart..year
fooroffered for sale.M
owner,
however.Ne building or improvement is old within ane yea ofimpro a for the pose of
buitoer will have Na burden of proving that he did our build or improv for purpose of
salt.).
❑1,as owner of the propeny,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7044,Business and Professions Code:)The Connector's U.
cons law does not apply in an owner of property who Wilda or improve thereon,and
who conuxets for such pmjecw with a eonnacmr(a)licensed pursuant to Bre Contractor's
License Law.
❑I am exempt under See. ,B d P C for this reason
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby aRirm under penalty of perjury one of Bte following duchmatiom:
1 have and will maintain eCenifieateof Cement to ulGinsurt for Worker's Compere
sedan.as provided for by Section 3700 of the Labor Cade.(m Ne performance of Ne
work for which this permit is issued.
ban and will maintain Workers Compensation Insurance,as required by Section
00 of the Labor Cade,for the performance of to work for which this permit is issued.
My Worker's Compienlsadon Innsunnm carrier and Policy number am:
Carrier: S. / O� Polity
C9.t7E OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thksecdon need not momni loted if the permit is forone hundred dollars($100)
M less)
1 certify that in the performance of Ne work for which this permit is wood,I shall not
employ any person in any manner an as m become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPUCANT:IL alum making this Certificate of Exemption,you should
become subject to Ne Workers Conformation provisions of Ne labor Code,you must
.J O fordowith comply with such provisions or Nia permit shall be deemed mated.
zr ti CONSTRUCTION LENDING AGENCY
[-+ I herebyaRrm Met ft.is.sued( ee.construction 0lenJing agency for the perfunnancc of
rl Le work for which this permit is issued(Sec.J09'!.Civ.C.)
Q Lenders Name
.7 z Lenders Address
V Q I ccnify that I have reed this application and slow that the above information it ,
ly F correct I agree to comply with all city and county ordinances and stew laws relating to
Ofd building construction,and hereby monotonerepresentatives of this city to color upon the
ved
W ahovom jusignums.men fandmpamans Purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ti y inconeupsom,ofth,coswang expenue which may in any way urnmagainstaald City
tJ,'� inconsequence of the granting of this permit.
APPLICANT UNDERSTAND WILL C�����w.....A11111PLY WITH ALL yj(1N-POINT Issued by: Date '
SOURCE REGULAU /
G�JAD Re-roofs
Signature of ApplicanHAZARDOUS MATERIALS DISCLOSURE DateI Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
oJc,Section `&115� - 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 g
mit hazaNnus air contaminants as defined by the Bay Area Air Quality Management all new materials for Inspection.
District' f) _
❑tics
I have mal the waaNnusmaurials requirements unser Chapwr6.95 of the Califor-
niaHealth&Safmy Com,Sections 25505,25533 and M534.I undem Na1if cul mg
dors not cuncn0y haw a unanL Nat it is my rcapomihility to notify Ne a pent of Ne
uquimmcnuJwr*h,tmeaa esprionuissumt racenifmaloof ry�p cy. Signature of Applicant Date
20 0
Owner or amhorizcd agent DateAll roof coverings to be Class"B"or better
08/20/2004 08:42 5302749311 TIFFdNY _ PAGE 01/01
,:. .._.. . .._ _..I_....
10300 TomAvwno
955
� dooCpeA 93at4
Tdopbo o(408)777-3228
Fut(408)7M-3333
CUPEkTINO .
Buildin De artment
JOB AODUSS: #
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Date
Sigty
Please check`s )i ole s nttact rs and complete the followin in£ormatfon:
aUBCOIL I BUSINESS NAME BUSINESS LICENSE
Cabinets Mill
Cement I
hlettiteal
Excavati
Fencing
Flooring.
Linol /:Woo
Glass
Iming
• Heating
tr�auietl
MOOM
La:ulsca ing
Orn ' tal M¢tal --
Paintin WaJI
PavhtB ._
Plastfixin
Pltim
Roofing
Septic T
Sheat M
Sheet It
Tilelow
Own o1�tr Signattue Date
. 10/29/03
CITY OF CUPERTINO
WATER HEATER b e�, o
CUPERTINO PERMIT APPLICATION FORM
APN# Date: / y
Building Address: �2 to
Owner's Name: Phone#:
1&14C -2s3 - 7550
Contractor: .I� Phone: License#:
L0a;&C1 -N2a� vo g 5 -S 3 41573
Contact: hone: Cupertino Business License#:
�w S
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
VO
Residential>— Commercial ❑
Cost of Project:
Strapped ❑ On PlatformEl BondedEl
New Location ElRe lacemenA
Qty. 'f
A l 1 Fee ID Fee Descri tion Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING