04020134-77
CITY OFCUPERTINO°F'a"*w
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BUILDING DIVISION PERMIT
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?CC1NT
BUILDING ADDRESS:
AAA FURNACE & AIR CONDITIO
PINGNDO4O2O134
OWNER'S NAME:
PERMIT ISSUE DATE
ONE: -
tang) 2ci-A-4,717
SANITARY OL NO.
ARCHITECDENGINEER:
BUtlA1NG PERMIT INFO
I
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
undernd
Oat 1unfthe
1ion7
Bu
with Section ]g1U)afDiviaion Sof dm Business and Pmfesslom Code, and myIkense is
)a( Professions Code. and
'
anifull tome and
Clam r? Lie. x� �
REPALCE WATER HEATER
Dem Coalition"
RCHITECTS DECLARA ON
I undcmund my plans shall he used u public mmrde
a�/ / Le
Licensed Professional
OW NER-BUILDER DECLARATION
1 hereby affirm that I am exempt from On Convector's License Law for the
following reason. (Section 9031.5, Business and Professions Code: My city or county
which nor lata a permit to calumet. alter, improv, demolbh, or repair any structure
prior to its issuance. also requires she applicant forsuch permit to rile a signed statement
Out he is licensed promises to she provisions of On Comuecter's Umnse Law(Chapmr9
Sq. Ft. Floor Area ValuatlO
(commencing with Section 7000) of Division 3 of Ne Business and Processions Cade) or
Out he is exempt therefrom and the bub fm the alleged Gumption. Any violation of
Section 7031,5 by any applicant for a pesmR subjects the applicant to a civil penalty of
3 2%f`V9%b t erO 0
Occupancy Type
.at more wn ova hundred doll. (5500).
L M owns of the propetty, or my employees wIN wages u tltelr axle compenss0on,
will do the work and die structure is notintended oraffered foals (Sec. 7040, Business
and Professions Code, The Conuncon. License Law gars at apply to an owner or
Required Inspections
property who buildsorimproves Oman. and whodoessuchwork himselforthrough his
awnemploycea, provided that such imp ovements an, nut intended at offered forsale. if,
however, rise building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
xle.).
❑ 1, as ownv of the property, am exclusively contracting with licensed contractors to
construct the pmjeci (Sec. 7044, Business and Professional Code:) no Contr¢tors LI-
'
wnse law does nut apply to an owner of property who builds or Improves theonon, and
who contracts for such projects with a conuactoKs) licensed pursuant to the Contractors
License Law.
I an exempt under Sac. ,B&P C for this owns
weer Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of On following declarations:
I haus and will maintain a Certificate of Consent to self-msoR for Workces Compen.
tion, as provided for by Schon 37M of the labor Code, fm the perfafmance of the
work for which this permit is issued.
1 have and will maimain Workers Compensation Insurance, u required by Section
of the labor Cede, far Ne, Ki fir mance of the work far which this permit is around.
My Warkere Compensation i umnce carie, and Polity number are
��s
Cartier. PolicyNo..JaG:423
C RTIM ATE MON FROM OR
COMPENSATION INSURANCE
(This section wed notbecomplemd if she pmmis is for one hundreddollan ($100)
nor text.)
1 certify, Nat In We performance, of No work for which this retain is issued, l shall not
employ any person in any manners ss in become subject to the WorkerY Compessatian
Laws of California. Dam
'
Applicant
NOTICE TO APPLICANT: IL Her making this Ccni0ca , of Exemption, you should
become subject to On Worker's Campeosdon provisions of the labor Cow, you must
foMwith comply with such provisions or this permit shall he ticemed revoked.
CONSTRUCTION LENDING AGENCY
Iberebyaffnm Out there is a consmetiot lending agency far On perfunsame of
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name,
Lender's Address
I certify that 1 have read this application and sum Nat the above Infomtatiun is
cannot. 1 agree to comply with all city and county ordinances and state Iowa misting to
building construction. and hereby nutation mprexnutives of this city to enter upon the
above-mentiowd property for inspection purposes.
(We,) agree to save, indcmnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and ..,emacs which may in any way acerae against said City
in consequence of the ginning of ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
E ULA NS.
Re -roofs
Type of Roof
�REG
�SO%U��
ur
Signature igAppliessidisconguiliar Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or building store or antic mamrial
mTowne
as ar. e, Chapter Health a
by the Cupanino Municipal Code, Chapter 9.11. and the Health and Safety
otic, Sccnon 35532(a)1
See
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will she applicant or future building Occupant use equipment at devices which
it havakour air conuminans an caused by me Bay Area Air Quality Management
all new materials for inspection.
Dinvin7
❑Yoe [Ju
I have mad the harab amatedais mWou"nutrader Chapter 6.95ofthe Califor-
nia Health & Safety Cade,, Serowe 23505,15533 and 25536.1 ondmsund thmifds, building
does not cuncntly have a temm, Nat it b my on umehility m County me mcupst of the
require cots which mug m�et Oat m issuance era Conifers, of«apency.
Signature of Applicant Date
]�bbse
K '9)';1]Q*
All roof coverings to be Class "B" or better
owns as
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CITY40
oCUPEkTINO
0
CITY OF CUPERTINO
WATER HEATER l
PERMIT APPLICATION FORM
APN # IR,,/
cJ0
-/!-D/2
Date:
D' - -off
Building Address:
Plumbing Permit Issuance
PLUMBING
Owner's Name:
Energy
Phone #:
BUSLIC
G
BUILDING
Con actor:
Phone:
License #:
Contact:
Phone:
Cupertino Business License #:
r,
Buildin drmit fo:
Bldg ❑
Elect ❑ Plumb
Mech ❑
Job Description:
m
Residential ❑
Commercial
Cost of Project:
Strapped 0
On Platform El BondedEl
ElReplacement
❑
New Location
Qty. if
Aoolicable Fee ID
Fee Description
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
PPERMPI'FEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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