04010060 CITY OF CUPERTINOh� I�+1eg��� -�a ,kL
BUILDING DIVISION PERMIT �i�.XC0NT—RWCTI'R ll�l". xRMf1TION:
BUILDING ADDRESS: HOT WATER INC PERMIT"04010060
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OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:00 LICENSED CONTRACTOR'S DECLARATION
Aro u I hereby.(firm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 701N)of Division 3 of the Business and Prefruimu Code,and my license is
in full force e d If
a'qi Licen les 6 ug.a WATER HEATER EPLACEMENT
p Dsu Contractor
q�q 7W ARCNITECIS DECLAR N
DR
U I un round my plans shell W useJ u public rccnrJt
k sea l"„ Licensed Professional
bH OWNER-BUILDER DECLARATION
<X I Wooly affirm Net I am exempt from the Contractors License law for the
00 following Munn.(Section 703 1.5,Business and Formations Code:Any city or county
which requires a permit to consouc4 alter.improve,demolieh.or repair any someone
Zee poor in its issuance.also Miuime,the applicant rot such Ferrell to file a signed statement
FF< that he is licensed pursuant toOle provisions ofthe CouncmriLicense Law(Chapter 9 Sq.Ft. Floor Are luation
Zs (commencing with Section 7000)of Division 3 of the Business and Professions Code)at
Nat he is eampt therefrom and the hues fon the alleged ewnptlon.Any violation of ya�.��yv'��
Section 7051.5 by any applicant for a permit subjects the applicant a civil penalty of 3�Grp Tyggagfa'r00 C anC e
not more than 0n hundmd dollars(5500). % p
❑1,as Owner of the property,or my employees with wages u Weir sole compensation,
will do me work,and the income is not intended oroffered for sale(Sec.7044,Buameu Required Ins eCtlOns
and Pmfeanions Code:The Communes Liame,law does not apply b e an owner of q p
pmpeny who builds or improves mereon,and who doessuch work himselforthmugh his /
own employees,provided that such impronmenu see not Intended or rlfeed for ule,If, /
however.the building or Improvement is sold within an your of completion,the Owner.
builder will have ren burden a(proving tha W did not Wild Or improve for purpose of
sale.).
0 1.as owner of Uro Property,am intuitively contracting with licensed contracts to
construct the project(Sec.7044,Business and Promse to Code:)The Convectors Li.
Cow Law dons not pply to an owner of pmpeny who Wilds or improves themon,and.
who contracts for such projects with a contr.morm)licensed pursuant u the Cornerstones
License Law.
0 1 am exempt under Su. .B A P C for this Mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 herby afforn under penalty of perjury one of de,following dahntions:
1 have ind will maintain a Ccrtirwe of Consent to seif-bume for Workers Compcm
7c,
ion.u provided for by Section 3700 of the Labor Code.for the perforrearce of the
W
for which this permit is issued.
./a ban and will maintain Worker's Compensation Iwrana,u"Wood by Section
0D of the Labor Code,for the performance of the wok for which one permit is iuued.
Workc' Cnm uatlon lnsecunna artier and Palin number art'mer.. TTL' k VIWI Poliry N., i74,.$�_
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need not w complerd If the permit Is Torun,hundred dollars(SIM)
or leu.)
I certify Net in the Perfnrmenee of the some for which this permit is handed,I shall not
employ any Norm In any manner se u in become subject to the Workeri Compensation -
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Confute of Exemption,you should
become Object to the Workers Compensation provisions of dead Labor Code you most -
.,z forthwith comply with such ptw4m.or this Permits hall W domed naked.
'E O CONSTRUCTION LENDING AGENCY
w�+ Ihereb affn that thce is a mruuuctinn lending s
F Y g gcrrry for the performance of
E
.�. the souk for which this permit Is issued(Sec.31191.Civ.CJ
Uncer
Ul Q CommIName
'7 z Lende'sAdd.
U 0 I certify that I bun read thlupplication and ole that the above information is
C) !'. wilds gree to comply with all city and county ntatnantts and emu law elating to
rV^ Wilding conswdiand her ureuthmiampmunutinsof this city censerupon the
LT7 ebuve-mc e)umdogretoCaProperty for indemnify
add keep
gL
(We)agree to con,indemnify sed keep hay[a a the City of against id try
Z inconsequ consequence
of the granting of thus
may in anyway accmc against mid City
V",[ A APPLICANT
of UNDERSTANDS
of orisDWIl.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURl'y-RCGULATIf]h(5.a /a
d(ca Re-roofs
HAZARDOUS
SignatureSignatureof APPlicaCon IBs��
HAZARDODO US MATERIALSDISCLOSURE Type of Roof
Will me applicant or lMuni building e.Chapter
aeM or handle hvardoOd Safety ety
u defined by dem Cupenina Municipal Code.Ch.pter 9.12.roti the HcsIW and Safmy
oJc,Section
35532(,)? *Nm All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant see equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardous air contaminants as defied by the Bay Area Air Quality Management all new materials for inspection.
imict7
❑Yee
Ihen Mail the hatardtmsmauoalaequimmcnuunder Chapter dh liffthC Wilding -�—
nicef.Ili S.fcry Code,kardrt.iet it
myrsnJ15534.10nortand Wuifmc Wilding
does rc cunentiy hon a tenant.that it i my issuance
of aiCety u wtil'y the attupant of the f�
eyuiMmciich mel poor so ofaCenifauo(.pcc ancy. R Signature of Applicant - Date
Owner or l lu ria .gem l/lY ate V All roof coverings to be Class"B"or better -
CITY OF CUPERTINO
WATER HEATER <' �' o
CUPERTINO PERMIT APPLICATION FORM
APN# 6 2 U 3o 2 Date: D
Buildin Ad re
�J6606,i944 6419
Owner's Name: Phone#:
-64t C � IL4 523
zJ v
Contractor: Pho (License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb J2, Mech ❑
Job Description:
Li K - A/07-A,4
Residential Commercial ❑
Cost of Projects .
Strapped J On Platform U Bonded
• New Location ❑ Re lacemenvl;b
Qty
A c ble 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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