03040117 CITY OF CUPEWI'INO 3 ?tea -� �''
BUILDING DIVISION PERMIT CONTRACTOR+INFORMATION ;`
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BY118W`1`9D"MLA LA WATER HEATERS ONLY PERMIT No.03040117
TP&TRIC W AND J R TRUSTEE 970 E . MAIN ST, SUITE 200 PERM"E"TT723/2003
Am hi�
(800) 835-5946
ONE: SANITARY NOO..4 CONTROL NO.
7, �O
CHITECT/ENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH
+ LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under provision or Chapter 9(commencing p
Section 700)(1)of Division 7 of Ne B.m...M Pro@ssiep Code,and my license is
' llrosaMt /o Lia ` 1452_3REPLACE WATER HEATERnxCl ss c t Comroctor l�VaaNd
7
ARCHITECTS DECLARATION
I lundcrsend an,plana shall Muudupublic ncnrda MAY 7 2003
a
CG Licensed Pmfcssiunal
5 Oat lam exempt
radDECLARATION
Ca I I owsm affirm Nm 1 ore exempt from the Contractor's Code:Any c Law I'm the BUILDING
m� whMO owing retes a Permit t 703 st.A Business mpr ve.Profession,h,oAny city or county
which requires a permit ha construct,the pier,improv,h Permit, fl repair any structure
prior its issuance,also rrquirtsthe applicant for permit to Neasigned naemcm
ss0 that he is licensed pursuant to Ne provision or the communes Liens,Law(Chaper 9 Sq. Ft. Floor Area syI6I9On
rH (commencing with Section 7")of Division 3 o the Business and Professions CWc)or Y
$
Out he is exempt therefrom and Ne basis for the alleged caemptlon.Any violation of
Section 7071.3 by any applicant for a permit subjects the applicant to a civil Penalty of 3�pN,{N„...i.,.r 0 0 Occupancy Type
not mon than five hundred dollars(5500). RA N Va TY`7
0 1,as owner of the pmpcny,or my employees with wages as their sole compensation, r�j� p7�Tp
will Pr dework.
nsCoand the he ctureCminanrn's Ltded Oroffereddoes am rally,704,4.Business 502 - FINAL �TT°F RGY
and Professions lds or The Contractors License Law doh ore apply m rt owner is RE A ti1KE
own enywho b,provied thatach improvements
who does n such wmkhtmulfur throughhis 506 - GAS TES
however.theca,ping or imrsuchentiss sold
within
net ear of omptc red ratable.If, 507 — FINAL PLUMBING
however.me building or improvement is told within one year of completion,me owner
builder will have the burden of Droving than be did not build or improv for purpose of
este.).
0 1.as owner of Be pmpeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- _
cane law does not apply to an owner of property who Wilds or improves Become,and
who compacts for such projacts with a contract h(s)licensed pursuant o the Conmactor'A
License Law.
0 1 un amnapt under Sac. .B k P C for this noon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following occlatatiom:
I hags and will maintain a Certificate of Consent to self-inure for Worker's Compere
.tion,as provided for by Section 3700 of the labor CMA,for Be performance of the
work for which Bis permit is issued.
I have and will maintain Worker's Compennion Insurance,as co9uied by Section
700 of the labor Code.for the performance of the work for which this permit is issued.
My Wor sC /p/g/�safo Inaunn//g cozier and Policy Mar am;
C.
Cartier., Il eo^"J Polity No.:/6D✓�(2'3 d
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This semi.need oat hecomplawd If the permit Is foram hundred dollars(SIM)
in Icss.)
I certify Out in the perfurmm is of the work for which this permit is issued.I shall not
employ any person in any mannenn as to become subject o the Workahl Compensation
Law.of California.Data
Applicant
NOTICE TO APPLICANT.If,arm,making this Contract,.of Eumption.you ihmu ld
become subject to the Worker's Compensation provisions of the labor Code,you mux,
�Z foMwtth romply with such prevision or this pcmbiuhall M ticemed evoked.
ZO CONSTRUCTION LENDING AGENCY
I hereby affirm Bat there is a construction lending agency l'or the performance of
Ya the work for which this permit Is issued(Sea XP7,Co.C.)
correct.
cd Name
7 z UndAddressAddrs
O 1 certify mat 1 have read this application and sue Bat On Above information is '
L F correrect.I agree to comply with all city and county ordinances and Cult laws relating to
C.) milocngconstruction,tioneand herebyauthonp represematiws or Bis city mercer upon the
C above-(We)agree
to sa y for inspection keep hs
(We)ogee to eve,indemnify and kith harmless Be City of .gamins against `
N liabilitiesjudgments,cosuang txpenxsmit. may in Any wayaccrue against said City /7
;J A consequence of the grunting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL ON-POINT Issued by: Date
SOURCE REGULATIONS. ��
9-3 03 Re-roofs
SignatureofA,Iwm VComm�y DT
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store or handle hazardous material
as defined by the Cupeninn Municipal Code.Chapter 9.12.and the Health and Safety
Cmde,Scctimn 25372(a)7 sH� All roofs shall be inspected prior to any roofing material being installed.
0 Ya
Wilt the mOI1Cmtm future Wildiag«cupamt use equipment or davices which If a roof is installed without first obtaining an inspection,I agree to remove
At harallous air=ontamim us u default by the Bay Ama Air Quality Management all new materials for inspection.
isuicR
❑Yes Cypsr• -
I have coal the haiaNnus materials requirements under Chapter 6.95 of the Cabral.
ria Ficalth&Safety C.M.Sccdun 235(15.25577 anJ255Ja,I uMcrsuntl Bw if du Melding
Ines not currently have a¢rima 0.1 it is my n rchichility he MILWY the t.Pant nr the
rtgmmmemm � mmprinr aananraceninaenraapanay. Signature of Applicant Date
owmr ter aamndu gin, DateAll roof coverings to be Class "B" or better
CITY OF CUPERTINO
aM WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 3 5 _ 13 _ () ,11 Date:
Building Address: /O�/7 n� � —
Owner's Name: Phone 25 S
Co -�t� Phone; License#:
M 274-3001 3 7S/573
Contac Phone: Cupertino Business License#:
Building Permit Info
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential X Commercial ❑
Cost of Project: ?a
/QO 0
Strapped ❑ On Platform Bonded ❑
New Location ❑ Replacement ❑
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
V
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