06010086 CITY OF CUPERTINO
BUILDING DIVISION PERMIT #CONTRACTQRNI('OI�ATIO ,Ei;
BUILDING ADDRESS: SOUTH WAY CONSTRUCTION PERMIT NO.06010086
rIQ941 WTTT,TNC(1N AV
OWNER'S NAME: PERMIT ISSUE DATE
MARVIN & BARBARA SPILEMAN 552 VERMONT 01/17/2006
NE: SANITARY NO, CONTROL NO.
(650) 245-2258
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
u F I hereby affirm That 1 am licensed under provisions of Chapter 9(commencing Job Description
`j with SecJon]00T))ofDivisian]of NC Businev aM Progestin sCnde,end mylicense is
Z, Wmnto=and effea (� ( REPLACE WATER HEATER
j ya i License Clue Lie.
�—❑ Dau Contractor
Y
qt5 EC
understandin sha
ARCHITECTS DLARATION
a 1 understand my plall he uas
sul u public rtrnrds
JyU
G to Licensed Professional 1
OWNER-BUILDER DECLARATION
<I I hereby affirm door I am exempt from the Contractor's License Law for The �j
i 00 following season.(Section 7031.5,Business and Professions Code:Any city or county /
K$ which requires a permit to construct,alar,improve.dcomfi h,Or repair any structum
°Zeprior In its issuance,also requires The applicant for such permit to rile a signed aluminum
Nat he is licensed purauanuo The previsions of rhe Contractor's License Law(Chapter9 Sq. Ft. Floor Area )✓aluation
y.$ (commencing with Section 7")of Division]of the Business and Professions Code)ser (e
Wt he is escmpt therefrom and the buns fm the alleges exemption.Any violation or
Section]0]1.5 by any applicant for a permit subjects the applicant m a civil penalty of
not mac than five hundred dollars(1k50o). P JU Occupancy Type
❑I.uownu of the propeny,amy wployces wish wegesudeir sule campenution,
will do the andk and the iructurm is ant intended or offered trial.(Sec.7044,Business
and Progenitors Code:The Conlrummr's License Law does not apply to in owner of Required Inspections
property who builds or improves thereon,and whodoessuchwork himself orthrough his
own employers.Provided thaswch improvements are not intended oroReres for sam.It.
however.the building or improvement is sold within one year of complcuon,dee owner.
indictor will have de burden of proving that W did nor Wild or improve for purpose of
sale.).
❑1,u Owner of the property,am ucluivcly contracting with licensed contractrs in
construct the project(Sec.7044.Business and Professions Code:)The Comeracbr's U.
cense Law docs not apply to an owner of propeny.who Wilds or improves thereon,and
who contract,for such ejects with a contoocmr(s)licensed pursuant o that Contractor's
License Law.
❑I am uempt under Sec ,B k P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I WsbY M.under penalty of perjury one of the following declarauou:
I have and will maintain a Car ifinu of Consent to self insure for Workers Compen-
sation,u provided for by Section 3700 or dm Labor Code,for the performance of the
wod for which this permit is issued.
❑I have and will maintain Wurlmes Compensation Insurance,u requited by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My WorkersCompensation Inwrsme carticr and Policy number am:
Cartier. 74r l'O//�E,l/ Poli,No.: y�2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need aotbccompleud it The permit is fm one hundred dollars(SIM)
or los_)
1 certify that in she performance of due work for which this permit is issued,I shall not
employ any person in my mannerw u in Wcome subject o NC Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate Of Exemption,you should
become subjccs to the Worker's Compensation provisions of the Labor Code,you mus(
.Jz foMwith comply with such provisions Of this permit shall W deemed mwked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm Out them is a construction lending agency for the perfurmana.f
LL' �✓ the work fur which this permit is issued(Sec.3M,Civ,C.)
W Lenders Name
=z lenders Address
U 0 1 cur ify that I have read This application and suite that the move information is
I.F correct.I agree to comply with all city and county ordinances and suns laws misting to
Q U building construction.and hereby authorize mprrunutives of Nu city in enter upon the
ifl imentioned property for inspection purposes.
H y (We)agree to save,indemnify and keep harmless the City of Cupcnino against
rA liabilities,judgmcnu,costs and expenses which may in try way accme against said City
U,z in consequence of Ne granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:_AP Date
SOURCE REGULATIpy$i _
Lir%//_\—F�!/1 t0/ h 12 Re-roofs
Sig�re drApplmsur C.robwcrbr Dau lLT
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or future Wilding account store or handle hanzrdous mautl,l
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
ode,Section 23532(a)?
❑Yes feTNo All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or roTam building Occupant um a If a roof is installed without first obtainingan inspection,I agree to remove
�OfiPP g e equipment Qu or devices which P
District? us air contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection.
❑Yes Wo
I have rtvl the Wnrdousmaurials requirements under Chap cre5.95 of the Califar-
nix HcalNhSafclyCode.Suurcm 5505.25533 and 25534.1 undersuM tha(ifte Wilding
does rpt currently have a tenant Nm it is my sex Tiliry b notify the occupunt of the '
myaimmenl.4 wnzn must Wmm p'or fe°o}:c Ee,ta or aetrp,n1,. Signature of Applicant 'Date
� � al1V AVV
owneror,wrmh<dagear� D,rt All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
'S Cupertino CA 95014
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: S 6 ' qR fr/ PHONE # ,f_
GENERAL CONTRACTOR:
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATERCITY
CUPEI�TINO PERMIT APPLICATION FORM
APN# l Date:
0
Building Address:
Owner's Name: Phone#:
S 2 ./q
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
i
Bldg ❑ Elect 0 Plumb IN Mech
Job Description:
Residential ® Commercial ❑
Cost of Project:
6'o a
Strapped M 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