05050114 (2) CITY OF CUPERTINO "^ 4•iw til=
BUILDING DIVISION PERMIT #CONTRACTOR INFORMATION
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BUILDING ADDRESS: HOTWATER INC PERMIT NOO 5 050114
OW NER'S NAME: PERMIT ESUE DATE
ONE: SANITARY NO. CONTROL NO.
(6SQ) 29R-R494
I
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONJob DcnptI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing rlfIfµ„ [��t,h Scai.n7IXN))nf Divixiun Sof NC Business and Pmfcssinnx Cedc,and mylienx is ���®full 1.meand effect.on,cla*•a Lk.a �� _ REPLACE WATER HEATER
�f O Da¢ CamonT —'
44,J —ARCHITECTS DECI.3 ATION
W I understand my plainshall be used as public ecm& _ p[
;0� Licensed professional 7005
3 OWNERexemptIRDECe Ccuro ON ��
<S I hcrchy afOrm thatOW I am exempt tram Nc DECLARATION
License Law for the
0 O following mason.(Section 7031.5,Business and Professions Code:Any city or county
=� which requires a permit to conswe,,aloe improve,demolish,or repair any structure
fZa Prior to its himmea..b.requires theapplicant r.rauch permits.Me a signcdauament
Nat he is[formed pursuant to the provisions of the Comment's Lorimar Law(Chapter 9 Sq.Ft. Floor Area n
tio
IE
(commencing with Section 700(b.1 Division 3 of the Busiocss and Profmirns Cods)io
i
that her is exempt thcmfrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of 3�r erO 0 Occupancy
not me man five hundred dollars(S500). P Y Type
❑has owner of Ne propmy,mmy employees with wagesas their sok compensation,
will dothework endo: Thema¢unot,Lt. Law
7044.owner
and ertywh bis cine:The ve thcraira acne Law ane: or apply 1.an r ugh ter ' Required Inspections
own em whobuildsorimprovesch im,mendwho docsinchworkhimselfor through his
own employees the Wilding
entsneneOnendedoroRmed sur ownle,Ir,
however,Nebuildingorimpmwmvinisxldwithin sur year of comPkGoo.the purpose
of
builder will have the Wrdcn of proving but he did not Wild or improv for puryoe of
sok.).
❑I,as owner of the proper;,am exclusively contracting with licensed contractors to
construct the Project(Sec.7044,Business and Professions Code:)The Contractors Li-
came Taw docs not apply 1.an owner of properly who Wilds or improve barren,and
who contracts for such projects with a contractors)licensed pursuant to the Conh aua s
License Law.
0 1 am exempt mode,Scc. .B&P C for this rcasen
Owner Dae
WORKER'S COMPENSATION DECLARATION
I bemby than under penalty of perjury ore of Be following declarniom:
1 have and will maintain a Ce,dficae of Consent to el6tnxm for workerscomis m
cation,as provided for by Section 3781 of the labor Code,for the Performanceof the
ork for,whieh tris permit is issued.
w have and will maintain Worker's Compensation Insurance,as required by Section
3700 or the labor Code,for the performance of the work for which this permit is issued
My Workers C.mpensati.n Insurance ark,and Policy number am:
/..,,� p.. �� J p n
Cartier.�=+/CERTIFICATE
EXEMPTION
XEM Policy Na.: O S YO'3�
CERTIFIC OMPE S TION INS FROM WORKERS'
COMPENSATION INSURANCE ,
This section need not W completed if the permit is ruro.e hundred dollars(SIM)
to loss.)
I seriN that in the performance of de work for which this permit is issued.I shall not
ample;any prison in any manner an as �ecy�nl bb1iaaaao the Workeri Contmation
pa
lawsef California D•• C
Applicant
NOTICE TOAPPLICANT.Ihaftc--�- r making this Ccnif¢mc TfsemPd
become subject to the workers Compensation provisions of the labor C.dc:you mum.
.J O forthwith comply with such pro,,wom or this pc.it mall W decmcd mvokod.
ZN CONSTRUCTION LENDING AGENCY
[-� I hcrehy,afford that them it.cemuuclum lariingageney for the performance of
ai 7 the work for which this permit is issued(Sea.3097,Civ.C.)
4 Q Under's Name .
Z Lenders Addreu
U O I cenify that 1 have mad his applicadim and sure don the show information is
W F Cenral.1 agree to comply with all city and county ordinances and sale laws relating to
0U building construction,and hereby thitherto,rcpresenutivcs of this city to enter upon the
above-mentioned pmperty for impaction purposes.
FaW. (Was)agree w inw,indemnify and keep harmless the City of Cupertino against
fq
liabilities.judgments.cosi mad expenses which may in any way acenre against said City
U in consequence of the gaming of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- OINT Issued by: Date
SOUR E�'iULAT1ONS.
S/ 6_ Re-roofs
SiSnaI..of Ap Iicam.Comsamor One
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicant Or future building mcupanumre.r handle hiscoilim,material
as defined by the Cupertino Municipal.Code,Chapter 9.12,and the Health and Safety
afc.Section 25532(a)?
m All roofs shall be inspected prior to any roofing material being installed.
]Y
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant infuture building oche B sex equipment or Marla which g
it haxardnus air contaminants as de0n d by the Bay Arca Air Quality Management all new materials for inspection.
uriclT
0
Yes
1 have mad the harardrms materials requirements under Chapter,6.95 of the Calif.,
ria Heal th&SafetyCook,Sectom 25505,25533 and 25534.1 undersand that ifbc Wilding
dins not only haw a enanh that it is my responsibility to notify the occupant of the
requin which 4 met pberwissuancc of a Ceddricae of cup y.
_- �/ G� Signature of Applicant Date
Owner or auberirrA egcm Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
// &d 8 161rcrih OSGSO/l �f
OWNER'S NAME: n 'h Sin PHONE #
GENERAL CONTRACTOR: ,- r/afcs /n FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
ba 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
t
CITY OF CUPERTINO
WATER HEATER
CUPEf�TINO PERMIT APPLICATION FORM
APN # 3&62 _ 5 — 07LI
Date: 5-1,2
Building Address:
Owner's Name: / Phone #:
( � n �! cw� vYl_ �0 8—LS S 3 S S-3
Cont *tor: Pho : License#:
t &1�-� /K C . Asa /-�yys� 3�2, ,1�
Contact: , Phone: Cupertino Business License#:
Arcs � u,s�a �/ (o S0 - 63/ - ala(�
Building Permit Info: /
Bldg ❑ Elect ❑ Plumb UY Mech ❑
Job Description:
1/0,4L'ir 1fC'a-�D�-� �c?�Sjl�is ,ec�S�i/vif5 r_' 7-/-J�'
Residential EK Commercial ❑
Cost of Project: ,/r`�U
Strapped 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
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