05050090 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,eCONTTRACTQIt�IFOATIUN
euaowcnooRFss: WATER HEATERS ONLY PERMIT NO.
-OWNER'S NAM PERMITLSSUB DATE
ONE: r SANITARY (iftOL NO.
7imto
CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONRACTOR'SDECLARATION Job Desc,1 hereby ar0rm Nat 1 em IicenseO under Orovelons of Chapter 9(commencing ���h Section 7000)of Division 3 offm Bust 3og&siyna Code, my Ucen srIfM4�ullforteend �-11 YYJJfan
nn `�"� Lm.e LACEWATER HEATER
ARCHrSDECLARATION ZU�[
' l uadersmad my plan NW k J
used a public records
is LkenmI herebyProfesoctal �■ pIp ®��
OWNER-BUILDER DECLARATION U L
En y 1 hereby.(lire o n 1 am exempt from dm Gonion Cor Lieenxe law for the
'a p O whichfollowing reran..(Section RD I.S.Buaineas and are.de inns Code:My city or county
n§2 which requires•pemiil ro construct,Altar.improve.demolish,or repair any stmemm
Firy^ prior m its issuance.Also requires the applicant for such permit in 01c ulgned stsmmem
Nu he is licensed pursuant In the provisions of the Communes nsc Law Sq.Ft. Floor Area Valua[io
F $ (commencing with Section 7000)of Division 3 of Ne Bumacen d Promsslons Code)or
IC that he Is exempt therefrom and fu basis far the alleged exemption.My violation of
Section 7031.3 by Any applicant for s permit subjects the applicant m a civil penalty of
not mom fun IM hundred dollars(5500). 3 GVFAL9I4i4N 0 Occupancy Type
a I.As owner arthe property,or my employees with wages As their sale compensation,
will dothowork.and thesuucrom isnotintendedore8crod famale(See.7044,Business Required Inspections
and Professions Code:The Conu Mor's Licee nsnse Law does sot apply m an owner of q P
property who buildmr improves furcon and wha does such work himself or through he
own employees,provided that uch improvements am not intended wnRamd ferasle.If.
however.the building or improvement is sold within aro year of completion,the owner-
builder will have the burden of proving fast k did nm build or Improve for purpose of
❑1,As mvner of fu property am exclusively contracting with licensed mnusemrs to
comtmct fu project(Sec.7044.Business and Professions Code)The Conuacter's Li.
cement law docs not apply m an owner of property who Wilda or improves tumor,and
who contrses for such projects with a emusemr(O licensed pursuant in dm Contractor's
License law.
Olamexemptura See ,B&PCfarthismamn _
Owner Das
WORKER'S COMPENSATION DECLARATION
i hereby affirm under penalty of perjury ane of fm following declarations:
7U..,
hamand will malnmin a CeslOcote of Came( self-imure for Worker'sCompen-
As provided for by Semm.3700 of the labor Code,for the perfmmmce of the
k far which this permit Is iarued.
have and will maintain Worker'Compen.tion InWramem as required by Section
0 ofthe labor Code,far the performance of fu work for which this permit Is Issued.
Woro a Ca n lnsu eamiar and Policy ro mkrer.`� PoIIry
CERTIFICATE OF EXEM MON FROM WORKERS
COMPENSATION INSURANCE
('lite W.reed notkcomphted Btk permit Isferome hundrrddollan(glg0
or kssJ
I unify that in fu performance of the work for which It,permit I issued,l Nall not
employ any person in any manner an as in become subject in the Workers Camp maidon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:Ir.after making this Cemincate or Exemption,you should
become subject to the worker's Compensation provisions of the lahw Code,you must
,J,Z forthwith comply with such provision or this permit shall Ise deemed rooked.
Z O CONSTRUCTION LENDING AGENCY
r�
[-. I homeyalarm Net them ie•ed(S .30 lending agency for the performance of
ai the work for which the permit is issued(Sm.7097,Civ.C.)
GQ Lendefa Nurse -
=z Lendeh Addm..
U0 I Certify dust I have rota this Application and nate that the above Infarnadt n is
ly^ COMM I a{me to Comply with all city and county Ordinances and sou[am misting to
Q rV^ building construction,And hereby"them.miummustives of Nie city no enter upon du
W shoes-mentioned Property fur inspection Purposes
G (We)agree m um.Indemnify and lump harmless he City of Cupertino against
fg Ilabillfu,judgeouts,cam and expenses which may in any way accrue egalmt std City
t),Z in canseguanee of the granting of this .h.
APPLICANT DERSTA DS WILL MPLYAWITH ALLN-POINT Issued by: Date
SOURCE RJCULAT14
_ 1.7 Re-roofs
Signature of AlrolkanUConD�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or(atom Wilding occupant nom or kMla harallom material
as
dc
by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
rade Section 2557zar All roofs shall be inspected nor to an roofing material bei. Installed.
E]Y., �� P P � Y g g
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haasNnm air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
DinricV l,�—
❑Yes Lieu .
I have mal the hantdnusmmrlals requirements underCkpter6.95of du CAlifor-
n1aHealth&SaR yeah,Somions 25505.25577 and 25534.I understand thetirthe building
dote not cunently hears a=m4 the it a my mspomibility m notily the eceupant of fu
requlremenu ' hmunkmelissuance aDam CcnifieamerCkca Signature ofApplicant Date
a •. S 1 uu_5Own DAll roof coverings to be Class"B"or better
Community Development
aCF
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
OUPEkTINO
Building Department
JOB ADDRESS: 75 9j C PERMIT# (D O g o o 9 O
OWNER'S NAME: mac_ PHONE #
GENERAL CONTRA OR .e FAX #
I am not using any subcontractors: L3 at, 4,.t dl, - _ `� 9/0 5
Signature T— 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
/ >> Tile �q
'/a-s
Owner/Contractor ignature Date
CITY OF CUPERTINO
WATER HEATER v S' s o10
CUPERTINO PERMIT APPLICATION FORM
APN# '3 ` L — 7 — 03 2 Date: s/� 7 l0 S
Building Address: /
59 3 ,2—
Owner's Name: S—tl— Phone#: 2 S 7 — Z pf 6o
Contractor: aha _ t4-2-o. Wine:
License#:
��ne: 8va 835 =596 3 7.N5 7-3
Contact: • Phone: _ Cupertino Business J icense#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description*
acr- 41-D 12.2
Residential Commercial ❑
Cost of Project: o0
�OD
• Strapped El On Platform El Bonded
New Location ❑ Re lacement'A,
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
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