04010058 (2) CI'CY OF CUPEWrINO '
BUILDING DIVISION PERMIT A"CONTRACT�OR INFORMAT,IION
BUILDING ADDRESS: HOT WATER INC PERMIT NO 04010058
OW NER'S NAME: PERMIT ISSUE DATE
1
ONE: SANITARY N0. CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION
d� 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
with Section 7000)of Division 3 of the Business and Professions Code.and my license is
: N inful1. amndef mw Lie.g
nse Z WATER HEATER REPLACEMENT
:z Liceass
Dem TgECL
I': ffECD
Contractor
AMON
1 undcodand my plans shall W used as public accords
JyU
G Licensed Pramual nnal
OWNER-BUILDER aexamDECLARATION
<E I hereby affirm on 1 am exempt from tW fessions Cs Licence ly far tW
0 0 following mason.(Section 71131.5,Business and Professions Code:Any city ver county
m winch requires a Ponall m constrain,alms.improve,demalkah,ver repair any urunum
_Zy priorto ins issuance.also requires the applicant for uch permit to file a signed statement
C that he is licensed pursuant to the previsions ofmcConundavr'sUccnmLaw(Chapter 9 Sq. Ft. Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y mal he or exempt momfmm and the basis for the alleged emmpdon.Any violation of
Section 7031.5 by any applicant far a Permit subjects the applicant to a civil penalty of 3M21Vb1hbu00 Occupancy e
not more man fin hundred dollen($500). P y `T7y p
❑1,as owner of the property,Or my employees with wage.Is Meir sole compensation,
will do the work and the nmmore is not intended or offered for sale 7064,Business Required Inspections
and Professions,Code:The Commetoes License Law dors not apply m an owner of q
property who build.orimproves Ncrcon.and who does.uch work himselfor through his - -
awn employees,provided that such improwments arc not intended proffered for sale.If,
however,the building or improvement 1t mid within one year of cmlR&Rdim.the mums.
builder will haw the burden of proving that he did not Wild orAproverfor purpose of
sale.). y�
❑I,as owner of the propert,am exclusively m
mnlracai ilp amrcromn
amerced can
construct the pmjca(Sec.7040,Business and ProlesCode:).* Candidates U.
came Law does not apply ne an owner of property w 'Ids m improves thereon_tin 1,
who contacts for uch project with aconlnnar(q lift- Ilpurauanl/to the'Conarictars.
Lie'..Law. /'
❑1 am exempt under Sec. rP C for this reason
Owner Dam
WORKER'SCOMPENSATIONDECLARATION
1 hereby affirm under perclay of perjury arc of the(ollowini declarabars:
I haw and will maintain a cenifieamof cement tomr-insum forwmkerscompen-v
7371W
ion,as provided for by Section 3700 of the Labor Code,for Ute o farr men of fipr
rk for which this permit is issued. \
I have Intl will maintain Worker's Compewdan bssurance,as required by Section
or the Labor Code,for Ne performance ofthe work for which this permit is Issued.
Work:r`s N=ian lmurame carrice and Policy number arae:��'']]rtier. / Va+O Policy No.: 15 40386
CERTIFI TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section wed not W completed if the Permit 1s for one hundred dollars tap j
or less.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ any pcomp in any mannterse as m become subject to the Workar'Campemadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifcale of Exemption,you should
become subject to the Workers ComPercadon provisions of the Iadv Cade,you am
.J O forthwith comply with such Provisions Of this Permit be decreed revoked.
'Z' ` CONSTRUCTION LENDING AGENCY
[-.r Iherehy affirm mat them is a construction lendingagemy for the performance of
a. ti the work fur which this permit is issued(Sec.3097,Civ,C.) -
A Undoes Nam.
D z Lenders Address
U Q I certify that I have need this application end sum that the atom Informatian is
F
comes.Igme to comply with all city and county Ordinances and sate laws relating to
�U building conaamction,and hereby authodm repremmstivrs or this city On enter upon Be
W .trovo-memicamd Property for ircpcction purposes
(We)agree la save,indemnify and keep harmless the City of Cupertino against
i.n fA) liabilities,judgments,cord end expercca which may in any way accrue against mid City
U Z in consequence of me granting of this Permit. [�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S Date
SOUR E TT�uQ�Ns.
=,a,e X71 /410yM 1410y Re-roofs
Signature of ApplicanHCo tracaorSignuurn of D�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uccupmutore or handle hmsrdorc material
as defined by use Cupertino Municipal Code,Chapter 9.12.and me Health and Safety
Coos.sanies 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant or future building occupant um equipment tar devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hanadom air contaminants as wined by the Bay Arta Air Quality Management all new materials for inspection.
isuict7
❑Yes ?No /+
Ihave read mehvardrds 2555, requirements under Chapmdquali(the Celdiag
-in Health&Safetyhaw.S wo,t 25X)5.255aand adhiht1 he badly
de Um Wilding 1\)
dm not cuamntly hew a moans that it a my msporcibility m notary the asuPant or the
���nuporacn be met pan,I.ismaneeaI Cerull I, fOczency' Signature of Applicant Date
�LI All roof coverings to be Class "B"or better
Owner or authomcd agent ate
CITY OF CUPERTINO
WATER HEATER U O
CUPEkTINO PERMIT APPLICATION FORM
APN#34 4 0_v Date:
r 1 Ll 03
Building Address:
1084e5' Zz,/6z,L nz
Owner's Name: Phone#:
r- /7.4 l e7 �-j (a -/08 0,964
Contractor: one: License#:
Alor w z c .5D) -) (-,'3 z
Co tact: one: Cupertino Business License#:
/4 La 6ui ( U Cosc?I G? - YF�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Prcje . �on 9
3
_ Strapped Ll On Platform L1 Bonded
New Location ❑ Replacement '—F�b
Qty. if
A li�able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE —Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING