04030145 dT,Y OF IJPERTINO41M,
BUILDING DIVISION PERNIITC1NT12ACTt1RINT'�UILMATI �,,
BCyiLDINGZO VICKSBURG DR ALL VALLEY PLUMBING PeaMlr.+.0
�1 .4030145
WNER'SPERMITISSUEDATE
yPVISIABE THOMAS M AND JOANNE 170 BRANNON DR 03/16/2004
7Dat
E: SANITARY NO. CONTROL NO.
252-4248 TRACY, CA 95376
MICTIENGINEER: BUILDING PERMIT INFO
] REPLACE WATER HEATER o eLecr PLO p
yLICENSED CONTRACTOR'S DECLARATION .
1 homey am.that 1 am IImuW u pmvWou of Chapter 9(commuoing lob Description
«tifi7 )u(Dlvbd.3ofNcBurinuk Dnp Pmfeavon Code, ndmyllcenxla
orte eRcet. Vt Camwne
tl Q ARCH5Ecrs DELLA A ON
Y (y3 1 undentud my plansa1Wl W uwd as plablicmoords
cad Licensed Pmfesdonal
OWNER-BUILDER DECLARATION
1 menu .(Sect Net I I. exempt from d r Comas Co License Law for the
00 following.loon.(SMiun7117L3,B cher.and Pm(drou Code;My city..roomy
$ which iuiuo a permit m uimik.ppli improw,demalUh,or repair .d structure
PHo.mslimm p. atiuirestha,iMomofdw Cohpermitm Oleaugnedsummem
zFF< Nns.n-tt withSectionloNepwvialouuftircC^numsenaluxuelaw(sCode)9 Sq.Ft. Floor Area Valuation
Sct (rnmmes exemiNSredon70ndd basis nal oftheegedeuudon.My
Code)or
3� Net he la exempt thrtfrom and Ne buss for Ne alleged exemption.MY violWon of
Semon 7031.5 by a"applicant fm a permit subjeCU the ePNleant to s civil penalty M APN Number Occupancy Type
not more than five hundred dollars($5007. -
❑1,u owner of Ne pmpeny,or my employcu wIN wage u thehmle campmadon,
will do lhemok and Ne.trumme tanmimended or.ffamd fox h,(See.7Paa BusinessRe aired Inspections
and Profession Code:The Contractors License Law dans ro �i
t apply av owe o _ q P
property who builds or Improve,thereon,and who dans such work himsellar through his _ _
awn ver,the
rns,provided thataoch Improvemwt sem ne year.ed m l.drrd der Owner.) ;--3
howeveroym, roAd.M.lwmmti.Ommumne)earofcompled.rytheair 11.r. , Iw
builder will haw did burden of proving that by did tot build m impmvi for p spise of r' n
ole.)• ( /�v I
❑1,u trop Of the property sem sin. ad contracting with I' eomaebn
mown the project(See.o an owner
of end property
who m Code:)The nuaemi' r
roue Law dans not apply m an owns.of property who builb or emprow Nereus and
who mcu naafor pmjeN m
with a eonumr(O pursuant puut Cone
License Law. '
❑lam exempt u^der See .B&PC(m NU noon
13700
er Dion
WORKER'S COMPENSATION DECLARATION
I hereby amrm under peulty of perjury oro of the following declarations:
have and will maintain a CeNOcate of Consent m self-inure for WorkcrsCompu-
m,u provided for by Section 3700 of the Labor Code,fm the pufurmama of the
k for which this permit Is Issued.
have and will maintain Walkers Compensation Insurance,u required by Section
of Ne labor Calc,fm Ne performance of dad wart fm which this permit Is leaned.
Workrs Compensation Ina ntt Cartier Iiry number art:
ry No: �,pr
CERnMCA E OFEXEMPIONFRO ORKERS'V • /7qa
COMPENSATION INSURANCE 4
flats acdu reed usbemmPleled lines permh U far..hundred dollar($100)
or less.)
1 modify that In Inc performance of the work for which this permit Is issued.l shall not
employ any Nixon in my murorso as to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making Nis CCnifiC.IC of Exemption,you should
become subject to 0a Workers Cmnpeoudon provisions of the Lehm Code,you mon
OZ forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY I
(-t I hereby a Mm wt Vert Ha couwuian lending agency for Nepermrmanm of
LL';> the work for which this permit k is ned(Sox.3097.Civ.C.)
W� Lenders Name
z Lenders Address
V Q I certify that I haw rad this application and sum Nu the above information is
eL!' conmt I,gree m comply with all city and county ordinances and nue taws existing in
C)SV^ building croswction,and hereby auNarim representative of Ni,city to enter upon the
lid above-mendoned property for inspection purposes.
(We)agme in use.indemnify and keep harmless the City of Cupertino against
,n liabilities,judgments.caw and eapeues which may in my way,ccnn against said City
V in eonseyurnco of Ne granting of this permit.
APP ICANT NDERSTANDS AND WILL COMPLY WITH ALL N N-P Nr Issued by: Date
S TIONS. "BlYD
Re-roofs
u f plica^UCanummr a
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will No applicant or future building occupant dare or handle heard..macrul
u defined by Ne Cupertino Municipal Code,Chapter 9.13,and the Heald and Safety
we,So y.a53z(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Na
Will the applicant or future Wilding occupant tae cyvipmrnl m devices which If a roof is installed without first obtaining an inspection,I agree to remove
colt huardnnt ale cm uminsnu as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes g7 No
I haw mad the haardusmwdal,mquimmenu underChapor S95of NeCtlifor-
ntat4.INkSafetyCode,Sections25X15,25533 au125534.I trunndnd Nu iftha building
does t current y by a mem.than it u my respouiht ry TnCury too occupan or the
my ihe mupdorwiuuanccohCcniEam.f cu y Signature of Applicant Date
. m All roof coverings to be Class "B"or better
aerod, cat
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
PEI�TINO
Building Department
JOB ADD
IW: PERMIT # G b Z
OWNER'S NAME: J PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 U14M --4�-
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�� ntr ct Signature Date
CITY OF CUPERTINO
o�D
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 3Date,:
69- i - _
Building Address:
Owner's Name: Phone #:
yc-4m 1119,96 02- 90
Contractor: �/ .Phone: O Li�gnse#: �9
Contact, (G(iyyl_ P ne: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: `
Residential 19Commercial ❑
Cost of Project:
trapped On Platform Bonded
' New Location ❑ Re lacement
PtflBENERGY
Fee ID Fee Descri tion Fee GrouPWHEATER Water Heater/VentPERMTI'FEE Plumbin Permit Issuance PLUMBING Energy BUILDING
BUSLIC Business License BUILDING