03080176 t CFPY OF CUPERTINO
BUILDING DIVISION PIRIVIIT COLVTRACTQI2INROILMATION '.
BUILDINGADDRESS: WATER HEATERS ONLY PERMITNG03080176
0140 ST-ONYDATE IDR
OWNER'S NAME: 970 E . MAIN ST( SUITE. 200 PERMIT ISSUE DATE
ONL': (800) 835-5946 MSANITARY 0. COAOL N0.
I� Liccmxc
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0 0 0
+OLICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licen=d under provisions n W�rya (commencing P
myliccna Is
AOf me antler( PLACE WATER HEATERq -
p Dam
e ARCHITECTS DECLARATION
E� 1 understand my plans shall he used as public records
aWU
a0 Licensed Pndcuianel
5 OWNER-BUILDER mDECLARATION
Ca I 1 masa affirm that 1 1. exempt from the Caxions is License Law for the
CMO whfollowinghequires apermin. t to construct.alter,
andve,dl.of Code:Any city or county
5$ which oyulTm a permit ra cons;t e6 applicant
improve,demolish, fi c a siany structure
-Z y pilo(In its laa"'p.alsont to the the roftheSatoh mon'toice sesignedaw(Chapter
-
aF< thatbe escingwiit pursuant to the provisions of NC Common's nd Proclaw(Code)or Sq.FL Floor Area Valuation
pp (cat be
(commencing Senion70nd)of the basisfro(the Business andon.Any
of
3 Nel he is exempt therefrom and the buss for Ne alleged exemption.Any violation of
_ Section 7031.5 by any applicansfor apevnitsubjectsthe applicant oacivil perally of APN Number Occupancy Type_.
not more than five hundred dollars($500). - - -'--' - --'-
❑I.as owner of the property,or my employees with wages as their sole compensation, p
will do the worst,and the structure is not intended or offered for 0W
sale 7 .Business 502 - FINAL R& (Mj c�ERGY
and Professions Cade:The Contractor's License law docs not apply to an owner of
ptnpedy who build&orimprnves thereon,and who deessuch work himselfor through his 506 - GAS TEST
owe employees.provided that uch improvements ma not intended ornfferet for sale.IL SO7 - FINAL PLUMBING
however,the building or improvement is sold within one year of comp4don,Ne owner.
build.(will have the burden of Moving that he did not build or improve foa purpnx of
sale.).
El 1,as owner of the property,am exclusively contracting with licensed contractors to - -
construct the pojeet(Sec.7014.Business and Pmfrsilom Curl The Convectors Li.
came,law docs not apply to an Owner of property who builds or improve Nemon,and
who contracts for such projects with a coronations)licensed pursuant to the Consnctora'
License Law.
❑I sus exempt under Sec. B&P C for this reason
Own Data
WORKER'S COMPENSATION DECLARATION
I hereby aRmm under penalty of perjury one of the following decimations:
I have and will maintains Ccnifia.m.f Cnnsenuo self-iasum forworkcr's Compere
salon,u provided Tor by Scedon 3700 of the Labor Code.for the pemforman=of the -
work for=beth this permit is issued.
I have and will maintain Weakeis Compensation Insurance,u acquired by Section
J of the Labor Core.for the performance or Ne work for which this permit is issued.
CMy a Work.(%�nmpjpsa,no Insgrance carrier and Policy numhram: � - -
CerricT: ,`5 /' iL Policy No.:
CERTIFICATE OF EXEMPTION FR WO KERS
COMPENSATION INSURANCE
(This section need not h.completed if the lcond is form=hundred dollars(SIMI)
or leu)
I cenify that in the performance of the work for which this permit is issued,l shall not
employ any person in any m=ncrsn u to become subject o the Workeri Compemation _
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should
become suhj=t to the Worker's Compensation provisions of the IaMu Code.you must
:lQ forthwith comply with such provisions or this permit shall be tamed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm then there is a construction lending agency for the performance of
.Z thc work for which this permit is issued IScc.3097,Civ.C.)
YA Lenders Nurse
1 z Lender's Add.
J Q I cattily that I have read this application and form that the above information Is
y Fcorrect.I agree to comply with all city end county ordinances and state laws mhting to
Q U building conummuon,and hereby euNomse rtprraenornive of this city to enter upon the
�.W ahov-mentioned properly for impaction purposes.
(We)agree no save,indemnify and keep hesmless the City Of Cupertino ageiet
n
h liabilitles,jud cots,cosh antl cx ms which may in'any way eccmc againsisaid City
J z in canseyu fNe gr n permit, a `��!'IZV\
^ APPLI UN D W ITH ALL bONP�JINf Issued by: Date
Re-roofs
Sigmwre of
HAZARDOUS
O am
DOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar Boom ipWildingle.Chapter
store or anodeh Health
anmamtial
u defined by the Cupertino Municipal Come.Chapter 9.12,and the,Health end Satcny
Cole,Section 255320)? All roofs shall be inspected prior to an roofing material being
❑vex P P � Y g g installed.
Will ehc applicant or lulure buiWingOccupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
in hasardo r,
s as dc0ned by me Bay Area Air Quality Management all new materials for inspection.
vics7
❑Ye Qrvu
I have mad the hanNOus materials requirements under Chapter6.95 of the Callror.
nix Health&Sof Code,S=tion 25 .25577 anJ SJq.IundersorM (the building
doe nonce Ihatcem t' vmyma Ndiny/o=ufy the supan fNe
myvi [ m p' organ Signature of Applicant Date
Owner tar emhorirsJ agent -
All roof coverings to be Class"B"or better
CITY OF CUPERTINO
isCCS" WATER HEATE
CUPEkTINO PERMIT APPLICATION FORM
APN# r®2 Date:
a�
Building Address: /v 19 1715,
A A
Owner's N e: of •C•c� Phone #:
7 7 8-0'15_3
Cont ct r: Phone: License#:
1, 27 1-3001 .3 7Y573
Contac Phone: Cupertino Business License #:
Building Permit Info
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
V
Residential Commercial ❑
Cost of Project:
Strapped ❑ On Platform Bonded ❑
New Location ❑ Re lacement ❑
Qty. if
A licable Fee ID Fee Descri tion Fee Grou
/ BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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