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CITY OF CUPER'1'INO
siz
BUILDING DIVISION PERMIT
W-QN;TRAGTOR FORMATION ,"
BUILDING ADDRESS:
235 24T. QT
HOT WATER INC
PEaMIr "o03090019
-I -INA
ER'S NAME:
2531 GRACELAND AVE
FEWIT ISSUE DATE
(650) 298-8494
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 busby affirm WI l am licensed under provisions of Chapter 9 (commencing
p
with Section 70)0) of DMxuon 3 of he Business and Professions Code. and my license is
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INSTALL WATERHEATER �t��q,,,�®
Out Lk.a
Date Cuntracorr s
ARCHITECTS DECLAR,4TION
I undvaumd my plans shall be used u public records
SEP 2 2 2003
Licensed Professore]
OWNER -BUILDER DECLARATION
I hereby alum that I am exempt from the Coalmnar's License Law for the
BUILDING B�'��
following reason. (Section 7031.5, Business and ProfessCode: Any city or county
{iions • e
Which requires • permit to construct. alter, improve, demolish. Or rtp d, any snetum
prior m its issuance, else requires the applicant for such permit to Glc a signed statement
Sq. Ft. Floor Area
Valuation
that ha is licensed pursuaduo the provisions of the Conwcwr's License Law (Chapter 9
.
(commencing with Section 700(d) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the Ensu for Ne alleged exemption. Any violation of
35621036.00
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a ave penahy of
nm more Nan five hundred dollars (5500).
- - — --
- '
❑ I, a owner of the property, or my employees with wages as their sole compensation.
— R � T��nm�p
Will do the work. add the nature is or intended or offered for .1. (Sec. 7044, Business
addProwhobuildskeimprovesmselm'. License
and The Cstheman, License Law dor wort apply m an owner
Vi7C9`lfl9p eC1100S
-
propnywhions builds or nd cottagerdoe work himapply arthrough his
is
2 02 - UNDERFLOOR PLUMBING
awn employees, provided that such improvement, are not intended or offered for sale. It.
301 - ROUGH PLUMBING
however. the building or improvement is told within one year of completion, Ne owner.
builder will have the burden of proving Out he did not Wild or improve for purpose of
302 - TUB & OR SHOWER
uk.).
502 - FINAL PLUMBING ENERGY
C3 1, r owner of the pmpeny, am exclusively contracting with licensed contractors to
construct the pmject (sec. 7614. Business and Profesatons Codc:) The Conlracmr's Lt.
506 — GAS TEST
core I.A. does not apply I.anowdr of property who Wilda or improves tharcan, and
507 - FINAL PLUMBING
who contracts for such projects with a contracmr(q licensed pursuant to 0m Cmnuactof's
Lic nse law.
I am eaempt under Sac. . B h P C for his meson
Data
-.
WORKERS COMPENSATION DECLARATION
Ihamy anion under Penalty of perjury one of the following cluluatlmru:
1 hats.' and will maintain a Cenifeste of (.'arose. to self -Insure for WmkefsCamped-
s dun, as provided for by Section 3700 of the Labor Code, for the performance of the
-.
were for which this permit is issued. .
I have and will maintain Workers Compensation Insurance, as required by Section
of the labor Code. for the performance of the work for which this permit is issued.
My Work C Knaaumn lnsursne" earnPolicydumbera .3 k(
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section reed not W completed if the permit is rare= hundrcddollats (S 100)
Or lets)
1 unify that in the performance of the work for which this permit is issued, l shall not
employ any person in any manner an u to hacomc subject o the WorkeW Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
become subject to the Workefs Com pedutmn provisions of the Labor Code, you must
forthwith comply with such provisions or Nis perm tt shall W doomed mrvoked.
CONSTRUCTION LENDING AGENCY
I hereby &Mrm that there is a construction lending agency or the performance of
the work for which Nis permit is issued (Sec. 3097. Civ, C.)
Lender's Name
Lender's Address
I cenify that I have mad this application and mm that the about information is
'
correct. I at= m comply with all city and county ordinances and stat, laws relating to
Wilding convection. and hereby submarine repmtentatim of this city to cntr upon Ne
above-mcrommul pmperly for inspection purposes.
(We) agree m eve, indemnify and keep hannlrs the City of Cupertino against
liabilities judgments. cess and expenses which may in any way aces siting said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -PO NT
SOURCE REG ?�pNS_ G/
O // 03
Issued by: Date
Re
-roofs
Signature of ApplicanUConnactaDa
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII the applicant or future building Occupant store or handle hada dour material
as deGad by the Colorado Municipal, Code. Chapter 9.12, and the Health and Safely
Section 25532(.)+ �,,�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment or devices which
emu humdmer oil contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes (CA,
I have mW the Incautious materials requiremcros under Chapter 6.95 of the Califor.
ria He.1"Solely Code, secWns 25505,25533 and 25534.1 undersmnd Out tithe Wilding
does Out currently have a tenant that it is my responsibility to notify IW usupant of the
requirementswhichmum W met prier he issuance of a Onuflute of ecu a�
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Signature of Applicant Date
O
All roof coverings to be Class "B" or better
Owner _TT
arautn rv,gerd
CITY OF
CUPEkTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
o3ogooi 9
APN # �
Date: q
G- O� a
Building Address:
cT
PLUMBING
BENERGY
Energy
Owner's Name:
BUSLIC
Phone #,
e�9 t 25——.�6
Contractor: Phone:
Ups
License
Contact: Phone.
Ck
eelCupertino
Business License #:
tick Gv G
Building Permit Info:
Bldg ❑ Elect ❑ Plumb LI
Mech ❑
Job Description:
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Residential d�q Commercial ❑
Cost of Project: c^.
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Strapped ❑ On Platform El Bonded ❑
New Location ❑ Replacement/1:1
Qty./if
ADDIfC$b�e Fee ID
Fee Description
Fee GrouD
BPWHEATER
Water Heater / Vent
BUILDING
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING