03070158 i CITY OF CUPERTINO �x
BUILDING DIVISION PERMIT CONTRACTORINFWRMATION 'r
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT N903070158
9756 1T1IQ9RQUR.Q DR
OWNER'S NAME: 970 E. MAIN ST, SUITE 200 PERMIT ISSUE DATE
NE: (800) 835-5946 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 a
y0o LICENSED CONTRACTOR'S DECLARATION Job Descri nOn
W 1 beauty arOrm that 1 am licensed under provisions of Chapter 9(commencing oP
?� with Section 70taIrr Division 3 of Rte Business anW Professions Code,end my license is
full to=and crect.LClass Lic.N �
®
Dal
Contractor REPLACE WATER HEATER
qq� ARCHITECTS DECLARATION
I.0 I understand my plans shall W used a public records n 0003
LLG Licensed Profeaiaml JUL 2 L L
OS OWNER-BUILDER DECLARATION
<f 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ����gE�G
f�
❑O following meant.(Section 7131.5,Business and Pmr,.mions Code:Any city or county IQV
x m E which requires a permit to construct,alter,improve,demolish,or repair any structurel�
FmPr' prions its issuance.also requires she applicant(of such permit to file a signed statement
££ 0
that he is licensed pursuant in the provisions oldie Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valualipp(,OO
C (commencing with Section 70B)a(Division 3 of the Business and Professions Code)or 4
that he is exempt therefrom and Ne baa for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjccu the applicant in acivil penalty of 3�� CiO O Occupancy Type
not more than Eve hundred dollars(SSW).
El 1,as awnm of the property.or my employees with wages as their sale compensation,
will do the work,end On dram uin Is not intended or off..d for .to(Sec.IDU,Business
and Professions Code:The Convectors Lipase Law does oat apply to an owner of co
Re red Inspections
progeny who builds or improves theromand who does such work himalfor through his 502 - FINAL PLUMBING ENERGY
..,.play..provided that such lmpnevemena arc not intended or offered ter aie.If, SO6 — GAS TEST
however,the building or improvement is sold within one)car of completion,the murder.
Wilder will have the Widen of proving than to did ret Wild or improve for purpose of 507 - FINAL PLUMBING
ale.).
t"s owner or the property,am exclusively contracting with licensed contractors to
.owma On project(Sec.7064,Business and Profession&Code:)The Contnnors U.
ccae Law deal not apply to an owner of property who Wilds or improves thereon,end
who contracts ror such projects with a commctor(s)licensed pursuanto the Communes
License Law.
❑I sem exempt uad.Sec. .B&P C far Nis..On
wn r Da
�OM ION ATIOAI
ercby alarm under Penalty of perjury one a the fallowing declarations:
I haus and will maintain a Cunificure of Consent to cel Ginsum for Wahar's Compere
sedan,ss provided for by Section 3700 of the Ichor Code,for the performance of the
work for which Nis permit is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code.for the pciformsnee of the work for which this pemrit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy h1u: _
CERTIFICATE OF 11KEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This sectlou need not W completed if the permit u for one hundred dollars(5100)
nrlesi.7
1 certify Out in the pmfnnnan o,of the work for which this Permit is issued,I shall not
employ any person is any manner an as m become subject m the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenipcaa of Esemption.you should
become subject to the Worker's Compensation previsions of the Labor Code.you must
.J O forthwith comply with such provisions or this Permit shall be deemed revoked.
Z'y CONSTRUCTION LENDING AGENCY
'f-..� Ihereby.lfrm that there is a construction lending agency fat the performance or
Wwork for which this permit is issued(Sec.)(Y)7,Civ.C.)
W A lender's Name
j z Leaders
nder'f Address
[)Q 1 certify the l law read this application and sate that the dba a infatuation is
O U come[,1 agree to comply with all city and county Dafinances and sate laws relating to `
building consu action,and hereby rotational repreanmives alibis city to enter upon the
a ahnvomcntioned property for inspection purposes.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
w to liar!l ides,judgments,casts and expenscs which may in any way eceme against said City
UZ in cansequcnce or the granting of this perm it.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. Z6
Re-roofs
ignat9re psi C facto Data
HAZARDOUS MATE LS DISCLOSURE Type of Roof
Will the applicard
m or future building cecupsat store or handle haauus material
as defined by the C.Nnino Municipal,Code.Chapter 9.11,and the Health end Safety
Code,Sc0Cy�15531(.)? Na All roofs shall be inspected prior to any roofing material being installed.
Will me applicam or ic building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardnus air camaminants a defined by the Bay Area Air Quality Management all new materials for Inspection.
a?
❑Yes
1 have read the haaNma materials requiremcna under CNpter6.95of the Caii(nr.
ni.HUIN&Safety Cndc.Seeduns 155)5,15533 and M534.1 unde.d that if the Wilding
deal oot cunemly law a arrant,Nat it is my iespomibility m notify the accupant or the
reyuircmcnu wbichm metpdor LoiUUMaora CeMflCaaef GCN ey. Signature of Applicant Date
7� tl
ser suthmiuJ agent Dare All roof coverings to be Class"B" or better
1
*-a3o70
CITY OF CUPERTINO
' WATER HEATER
CUP 11TINO PERMIT APPLICATION FORM
APN # 3 /qr 1O — V L1 — 0 O Date:July .2/ 00.3
Building Address:
Si r'cksbur r;✓e u erfirlo, ✓
Owner's Name: rQ�K Gh4n hone #: p
352— G S'7 «q�J?0-
Contract License#: 'yb;7
Iffier eaters D,n ( . 1he• 7573
Contact: r / Cupertino Business License #:
r C
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
_ di old w e✓ a ✓
Residential _ Commercial ❑
Cost of Pr ect* OO
F.&,—rapped On-Platform Bondedw Location ❑ Re laceme
Qty-jf-
Appjiba0lFee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING