05060003 . CITY OF CUPERTINO t a '^ '�+� �' ��' '�"' •�,':,
BUILDING DIVISION PERMIT 1CUN'I=RACTUR MID ATIO
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BU ILDINO ADDRESS: PERMIT NOD 5 0 6 0 0 0 3
OW NER'S NAME: PERMIT MW OATS
EQUITY OFFTrR
ONE: SANITARY 0 CONTROL NO.
ARCHMECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 r—=
0 0
am'z LICENSEDCONTRACTOR'SDECLARATION Job Description
1 hereby ) fm that 1 Am fOnBu under provision of Chapter 9(commencing P
wish Scotian 7M)of Division Sof me Business and o(essiuu Code.and mylicense 0
^� mfull fortt and cf rot.
pz uctnmc s__ — uc.g REPLACE WATER HEATER
�— Dam Contracts, CONTRACTOR: PLUMB PERFECT INC.
9 ARCHITECTS DECLA� i
1 underwnJ my plans shell he used u public meads
30 Licensed Prefcaslonal
5
OU TION
I hereby affirm mat I am exempt form the Contracmf
s L{ants Law for Ibe ((,1 A5
i a 0
following..an.(Scethm 7051.5,Bottom and Pmftas ms Calc:Any city or county /I f( I' � n�
u�I which requires a permit m cnnauuct,alter,Improve.demolish.or Milan my Alructure IIUII ll
FZY poor to its issuance.also requires the applicamforsuch permh to file a stand statement
Him that haislicensed panuan(tothe pmvismnmfthe Cmuractsraldeme,Law(Chapm9 Sq.Ft. Floor Area ,;Valuati
$ (commencing with Secuon7O0o)of Division J of the Susumu and Professions Code)of 4-�
— 000
that he is exempt memfrom and the hands for the Alleged excerption.My violadun of
Section 7031.5 by any applicant for a permit subjects me applicant in a civil penalty of APN Number , [UUJ Occupancy Type
no,mace Nag five hundred dollars(M). f7 n
❑I.asowarofthepropeny,or myeeres fl
ploywith the'v telt compenution,
will do the work and the smrmune la trot mounted"offered for sale(Sm.7044,Burinv ��•r++' +r•: IA
and Foliated. Code:Z ComracmYs Lkeme Law dog act apply ts an owner of Required-.IApecuons
propenywhu builds armmprows mercon,andwbadoutuchworkhimmlforNmugh his O Ll
own employes,provided that such improwmenu art netI.,-. moRened for sem.If.
however,the building or Improvement is mid within can year of completion,the owat.
builder will]have the burden of proving dot he did not bmdld or improve for purpose of
axle,).
❑1,an awar of she property,am nclusively contracting with lic u and conbaemn to
construct the project(Sec.7044,Busiass and Profusion Code:)The Contrctor's U.
tense Law dean not apply to an owner of pfopeny who builds or improves Nemon,and,
who conwcu for such pmjccu with aeonuacmKU licensed pursuant in Ne Comrmtsts -
License IAA`-
0 I am exempt under Sec. .B At P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury on of On following declarations:
I have end will mainain a CenlBga of Covent m coif-iuua for Wlakees Coropeen.
goon,As provided for by Section 5700 of the Inbar Cade,for me performance of the
work for which Nb Permit h Issued.
❑I law and will maintain Worker's Compena0an Insurance,As required by Section
57M of the Labor Code,for the perfamana of the work for which this permit u issued.
My Worker's compens�ati%on�In canna timer and policyn be am:
Cartier. �JYi'L gyfJaA1D Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thmsection Aad not be completed time permit is faonhmdoed dollm($IW)
or leu.)
I gory that in the performance of the work for which this permit is issued,I shall Am
employ any Moon In any manner An,as m Mcome subject be the Workere Compenudon
Lam of CAlifomlA.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you mould
become subject to the Workct'a Compensation provisions of the Labor Code,you mus
.J O forthwith comply with such provision or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
ti ti
[—m work
rwhichby this
met merc{aaed(m.hm 307,Cing .) for the pelf urmenaof
Ik the work for which tela permit is issued(Sec.3097,Civ.C.7
W Q Unds Name
Undoes D z ndoeeya Adtlress
U0 1 certify that 1 haw mad anis Application and sum aces the allow information is
D,FconcL 1 agree incomply with as all city and county ordinmand sum lawn muting to
DU Wilding construction,and hereby aumodm representatives ofmis city to cots upon the .
I27 xbow-mentioned pmMny for inspection purposes.
C (We)Allen so taw,indcmniry and keep harmless the City of Cupertino agamst
o liabilities,judgmem.cow and expenses which may in my my acaa&Soot gid City
C.) in consequence of the gaming of this Permit.
APPLI NT DE AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU RE
sg9. rPafF App1 n We rant r Ip p�Q_ Re-roofs
HAZARDOUS h ERIALS DISCLOSURE Type of Roof
Will the applicant or future building oaupanumre or handle Institutions material
As dellned by the Cupenim Municipal Cade.Chapter 9.12.and the Health and Safety
Calc,Sidon 25552(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yg �Na
Will act appnanI.,future building Occupant use equipment ordevces which If a roof is installed without first obtaining an inspection,I agree to remove
Pitthavardnu sir curnaerinann u Jelled by me Bay Area Air Quality Management all new materials for inspection.
mitt?
❑Yes `VN.
I haw mall the hunouus materials requirements underChapter6.95ofthe Califor-
niakmalthAtSafetyColt,3ectiom 25505,25553 and 25534.1 understand thmifmho building
Jas not curcn naw imm a t Ice y leeponsibllity m natil'y dm occupant of the
requlremenu i mu r maflce,tine,teor0aopanay SignatutoofApplicant Date
Owner ar cut eco ate All roof coverings to be Class"B"Or better
CITY OF CUPERTINO // Day
WATER HEATER 03 u
CUPEI�TINO PERMIT APPLICATION FORM
APN# 51(p 10
D 3� Date:
Building Address:
106190 N . J
Owner's Name: Phone#:
E- Q u I I orFILL
3 y _ deo
Contractor: Phone: License#:
wm-5 . 0 274
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ® Mech ❑
Job Description:
E c h— fc
Residential ❑ Commer&al
Cost of Project: 1-ci �oo�
• Strapped KI On Platform N Bonded LM
New Location Replacement El
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING