05040186 ' CITY OF CUPERTINO
BUILDING DIVISION PERNIITCONTItAC'Ta 'CNFURMATON „
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BUILDING ADDRESS: WATER HEATERS ONLY PERMrrN 05040186
r
OWNER'S NAME: PERMIT ISSUE DATE
ONE: ' S79i TS SANITARYO. OL NO.
CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELF.L7 PLUMB MECH
30j LICENSED CONTRACTOR'S DECLARATION Job Description
rd+d I hmeby sfRrm Net I am liana m undro
er visimu of m
Che 9(comm. I.,
nt1`yf wiNSccuon700(fol )ivWan3ofdw Bust Mprofo s Nmylic :r
in full fortx and a
a Licenseyss PLACE WATER HEATER
' p Dom J amnion,
7W saAR Wan DECLARATION
1 undernd my plans
b ns MVI useA AS public ocnNm
ional
c LicenseI hereby affix
OWNER-BUILDER DECLARATION
a F I Mosso .(Seco on 1 am exempt from me Contractors e:Any c Lew for the
i.O O following mason.(Suction 7 o I.S,Business and va,de u i Code:Any tiny or county
$ which tits bane permit re core the alter improve,demolish,or mash ed structure
monotone
than he itsbanned,Alsorequiresft thcappin of for Cchpermit wfile
se Law(Chat=
hat=9
< NnMislittmed pursuant 7000)of Division
the of
nuxmfsnicc�Is...Can ur9 Sq.FL Floor Area Valuatio
Ila
that he ndng with Sereirom and de basis
r Sh the Business ed xe and Prefixaon.Anynns Cndc)of
a.. that he 7 exempt therefrom end Ire aper Tar dm alleged exemption.to Any l lemon of
Section 7 am five
any red Applicant fa a permit subjects the applicant m a civil penalty of
but mom than raw hundred dales,({moo). 3-AY4r0 O Occupancy Type
❑I,ummrofthepmperty,ormyemploycawltbwg"nteirulecompenudon,
wtilde the work.And the muctum IS not mudded mutilated fmaale(Sec.IDM.Bumust, Required Inspections
and Prossi
feons Code:The Conaumme me nsr's Licelaw does l Apply m an owner of q P
property who builds or impmma thereon,and who does ouch work himself or themugh his
own employees.provided that uch improvements Am not intended oroffere l(orale.11.
bowever.our building or Improvement Is sold within am Year of comPlenion.the owner.
builder will have the aurden of proving that he did not Wald or improve for purpose of
ants).
❑I, a owner of the property,am exclusively contracting with licensed contractors to
constroet the project(Sec.70M,Business and Pmfeulons Cade:)The Contractors LI.
cense law does not apply An an owner of Property who bilds or improm themon,and
who canmcu for such projecu with s contranAds)licensed pursuant in the Convectors
License Law.
❑I Am exempt under Sea .B sit P C for this mama
Owner Data
WORKER'S COMPENSATION DECLARATION
1 body Linda under pointy of perjury am of the following declAtulons:
1 haw and will maintain aCeNEau of Consent to self-ileum for Workefs Compco-
Milan,M provided far by Section 3700 of she labor Code,for the performame of the
work for which this permit Is issmd.
have and will animatn Worker.Compensation insurance.u required by Section
W of the labor Code.for the performance of she work for which this permit is issmd.
My Worker'Compemadon unnmJder and Policy numWrare:
Canner. Polley No:L�1U�O N-'71�
CERTIFl TE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
Clhr section need cot bcompletad If the permit doom hundred dollars($100)
or lemW
1 certify Out in the performs...of the work for which this permit is hand,1 shall not
employ any parent in any man u rso AS An become subject in Ne Worked'Compematlon
4wsof Califomla.Data
Applicant
NOTICE TO APPLICANT:if.After making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of me Latta Code,you most
.,0 forthwith comply with such provisiau or this permit still b deemed invoked.
z CONSTRUCTION LENDING AGENCY
1 hereby allLm that thea is a construction lending agency l'a One perfurmum of
pi the work for which this permit is issued(Sec.3097,Ch,C.)
W Lender's Name
PZ Lenders Address
U O i certify that I have read this application and mute that the above informadun r
W correct.l Agree an comply with all city and county ordinances and sure law mlating to
O building construction.and hereby Aummise representatives of this city to enter upon the
W above-mentioned property for Inspection Purposes.
(We)ago.to ave,indemnify and kmP harmras the City of Cupertino against
In liabilities.Fragment.costa and expenses which may in My way.cemc agdnst Said City
U v'+ APPLIC UNmn{u ng S ND Wl COMPLY WITH A NON-POINT Issued by: Date
S S,
ylL-l5 Re-roofs
HAZARDO
Signature of AppliuData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the Applicant or future building aceupantsoo or handle haeallous manorial
AS dcOned by Ila Cupentm Municipal Code.Capper 9.12.and the Holm and Safety
AIJG.dn. All roofs shall be inspected prior to any roofing material being Installed.❑Yc. gNa�
V411 the Applicant afuure building occupant use equipment mtkv{ma which If a roof is installed without first obtaining an inspection,I agree to remove
emu haordnus air contaminants AS delincd by the Bay Ares Air Quality Management all new materials for inspection.
District?
❑Yes 93Lftr_ —
I hoe oW the heondmm materials requirements under Chapter 6.95 ofthe Califon
nia Health B SafetyCode.Sodom 25505,25533 and 25530.1 understand that If the building
data not cunentty hoc•IananL that rat r my responsibilitym nail'y me ac ant of me
requlremcou which moat be miuuutae ACenifuata of Signature Of Applicant Date
Owner or emhonted agent „� All roof coverings to be Class"B"or better
Community Development
. �' 10300 Torre Avenue
' r Cupertino CA 95014
Telephone(408)777-3228
CI Fax(408)777-3333
OUPEkTINO
Building De artment
JOB ADDRESS: 704 S-g-,g � _ PERMIT#
65 a V6 /k6
OWNER'S NAME: /� a�u%w_. PHONE # �o2-ov4�
GENERAL CONTRACTOR: .aAL,, FAX #
I am not using any subcontractors: L3 at, �4j. (]ln� -�$ _ `� ?/a 5
Signature T— Date
Please check applicable subcontractors and complete the following information:
60 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 �pp
Owner/Contractor ignature Date
04/28/2005 22:54 5105383282 LEGALITIES INK PAGE 04
Bonita J. Jenkins
' CITY OF CUPERTINO North Bay Permits
ax.. WATER HEATER (510) 541-1232
ICUPEkTINO : PERMIT APPLICATION FORM S� ��Sb
APN#
Z Date: 2 v
Building Address:
Owner's Name: Phone#
Contractor:Gt/i� J/� y Phone: License#:
lV O'Do 8'35 -S9'16 3
Contact: Phone: Cupertino Business License#:
98b
Building Permit Info: .
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: _ n
Residential Commercial ❑
Cost of Project:: s
X75 .
Strapped ❑ On Platform ❑ Bonded
New Location .❑ Re lacement�
Qty. if
Anblicable Fee ID Fee Description Fee Group
1I BPWHEATER Water Heater/Vent BUILDING
/ :PPERM=E Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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