04010055CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
zACO'N`Ra^�ACQR INFORMATION-.d. '.
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BUILDING ADDRESS:
'HOT WATER INC
PERMITNO 04010055
OWNER'S NAME: -
PERMIT ISSUE DATE
TAM
DNE:
SANITARY NO. CONTROL NO,
(650)298-8494
50 298-
ARCHITECT/ENGINEER:
ARCHITECTIENGINEER
BUILDING PERMIT INFO
BC,Q4a ELECTPLUUMMB MO
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LICENSED CONTRACTOR'S DECLARATION
1 hereby aRinn that I RM licensed under provisions of Chapter 9 (commencing
lob Description g')
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with Section ]WI)) of Divixion J of Inc Business end Prefcuinnn Codc. end my license is
In am` ,. Z
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WATER HEATER REPLACEMENT AUG
License
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g
Dale - Com
2o0a1
I"S DEmr
ARCHITECTS DECLARATION
I un crs.nJ my plana shell he used a public records
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Licensed Prnfcssinnsl
OWNER-BUILDER DECLARATION
1 hereby affirm 'hat l am exempt from the Commodes License Law for the
.
following reason, (Section 7031.5, Business and Professions Code: Any city Or county
which rcstand. a pc.itm construct, alter, improve, demolish, or repair any structure
prior in its ssce
ivan, also requires be applicant for such permit to Ne a signed statement
that he is licensed pursuant Lo the previsions of the Connectors Licorice Taw(Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 71(1 of Division 3 of the Business and Professions Code) or
_
that he is exempt therefrom end not basis for the alleged exemption. Any violation of
361P191�1D161Tjer00
ane
Occupancy
P Y Type
Section 70315 by any applicant for a permitsubjects the applicant to a civil penalty of
not more than five hundred delta. (SSW).
❑ 1, as owner of the pmpcny, or my employees with wages as their sole compensation,
will do Rhe work, and the swnure is not intended or offered for sale (Sec. 7W, Business
Required Inspections
m
and Professions Code: The Cememrt License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc not intended oroRemd forsale. If,
however, the building or improvemem is sold within one yeti of completion, the owner,
builder will have the burden of proving Nn he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors ,o
construct ,he project (Sec. 70n4, Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who builds or improves themed, and
who contracts for such projects with a contmcmr(s) licensed pursuant to the Co cadets
License Law.
-
❑ l ren exempt under Sec. . B & P C for this mazon
Owner Data
WORKER'S COMPENSATIONDECLARATION
I hereby afMn under Penalty of perjury one of the fallowing declarations:
1 have and will maintain a Certifmle of Consent medr-I sure for Worker's Coder.
'
anion, a provided for by Section 39W of the labor Cade, for the performaem of the
-
wed for which Nis permit is issued.
have and will maintain Workers Compensmiem Insurance, az required by Section
900 of Inc labor Code. for the performance of rise work for which this permit is issued,
My Workers m enaetied loodoe s, aorta, and Policy mot er aym:� �' �
Cartier. ( Nye Policy No.:�V4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThBsection need not he completed Ellie Permit is for one hundred dollars ($I00)
M less)
1 certify that in the performance of the work for which this Permit is issued, I shall not
employ any person in any manner an as to become subject to the Workers'Compcnsation
,
Laws of California. Data
Applicant
.
NOTICE TO APPLICANT: IL after making this Ccroficine of Exemption, you should
become subject to the Worker's Co nNess,ion provisions of the Labor Codc, you mus,
-
forthwith comply with such previsions or this perml, shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a consio ction lending agency for the Performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and atam that the above information ii
correct. I agme to comply with all city and county ordinances and sum laws rclraing to
building construction, and hereby authorise hiPmsenl2dwal of this city to note"I nn the
above-mentioned property, for inspection purpose&
(We) agree to save, Indemnify and keep ha ICU the City of Cupertino against
/
Liabilities, judgments; costs and expenses which may in any way accrue against mid City
in cmdequcnec of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
tl//
Issued by: Date
SOURCE R�Gfi6sAT S. ., —T//(L/�L�
Re-roofs
Type of Roof .
Signature of AlppplimnUComru or / Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Den, store nr handle hanNous material
as defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
cede. Seen.. 25533(x)+ \\''
1
All roofs shall be inspected to an roofing bei.
being installed.
year [�4e
prior material
P P Y g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
i, havardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
hillw P ,/
❑secs rkN.
Ihawre NehavSectorsJma Chapmrh95 of the
t 505,25533rementsundcr
his Health &Softy Codc, Sectors ]55115, 25533 and 25534.1 undcrsmnd the, if Inc heildin
Wilding
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docs not Comedy have a moan, that i, is my res onsihili,y m oddly,he occupant of the
rcquircmenss hemmpriorloissuanceof. cerdidw. 0ccu cy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner oranMond asem,
CITY OF
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
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APN# �2 c� 0
Date: 6116
Building Address:
8
PPERMIFFEE
Owner's Name:
Pho#:
L9 M i�� t.,w
�Jg63-7%-2
Contractor: Pho --
License #:
o- c ,� -� - �3
�)63G�
Contact: one:
G ' 8�!
Cupertino Business License #:
11911 a/W Uf
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Mech ❑
Job Description:
Residential] Commercial ❑
Cost of Project: 3r60 ✓
Strapped ❑ On Platform ❑ Bonded
New Location ❑ Replacement %3 -
Qty.
ADDlidzabVe Fee ID
Fee nr.ccrintinn
Fna rrnnn
BPWHEATER
Water Heater / Vent
BUILDING
PPERMIFFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
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