03080144 (2) CITY OF CUPERTINOr',�`+-'�°E="+"s•" +a'+w.a�t {w
r BUILDING DIVISION PRRMITCONTRACTnR�INFORMAT10N;
OUILDINGADDRESS: HOT WATER INC PERMITNO03080144
S
OWNER'S NAME: 2531 GRACELAND AVE peRMITlsusDATE
ICK HIPHT, OA /9 -Z20f)-A
(650) 298-8494 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
too LICENSED CONTRACTOR'S DECLARATION
�Za F I hereby affirm that I Am licensed under previsions of Chapter 9(commencing Job Description
a< with Section 7")nf Division 3 of the Business and Profcssioas Cma.md my licon,c is
<„ in force and cffec� 6�+ ` LM g 3 Z REPLACE WATER HEATER
1 ? LiceDatcn�Y/
e3�
ARCHITEContractor
CTS DECLAR TION
` I undcrttanJ my Place shall he used As public records
>du
c� Licensed Professional
5 Oat I am exempt
fo DECLARATION
COO hereby.(Siem 11. exusin from the Contractor's Code:An, Law for the
00 following.mon.(Section 1. IInIS,Busim,.sland vers de oli h.a, e au,m nr county
COO
� which reyuirca a pemsit ht cnnumcl,alter.impmw,demnlLcR nr repair any structure
prior in its issuance.aim coquina the applicant for such permit to rile a signed statement
Sothat he is licensed punuent m the provisions of me contractors License law Claim,v Sq.Ft. Floor Area Valuation
2'y,t❑ (commencing with Section 70th)of Division n of the Business and Professions Cotter)or
L 3$ that be B exempt menfmm and de basis fm Be alleged exemption.Any violation of 32658016 . 00
Section 7031.5 by any applicant for a Permit ubjects the applicant Los civil parially of APN Number .. - Occupancy Type
not mom man Rw hundred della.($50(r). - -
❑I,As owner of the property,in my employees with wages As their Aute comp msetlon,
will do the wart,and the structure is not intended or offered for sale(Sec.7044,Business — iRLWNJAFtCWAFRGY
and Professions Code:The Contractors ns License law danot apply m an owner of 506 — GAS TES 1 PP��
property who build,or improves therm.,and who docssuch work himself or through his
own employees,provided that such improvements art not intended oroae,ed forale.If. 507 — FINAL PLUMBING
however,the building or improvement i,mid within one you of completion.the owner.
builder will Mve she burden of proving that M did Out Wild or improve for purpose of
ale.).
❑I.as.wncr of the property,am exclusively convecting with licensed convectors to —
contract the project(Sec.7014,Business and Professions Code:)The Convacmra Li.
cans.taw does at Apply loan ower of property who Wilda or improve IMrton.red, �__
who connects farmch pmj.cswith.cortracm,(.)licensed purtumuo dm
License Law.
Q tun em.ps under Sea .B kPCfAthi,mason
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby Affirm under penalty of perjury am of the following dxlaretlam;
I how and will maintain a Cerdficme of Consent to self-insum for Worker,Compi
I�T3111 .ftlh.
on,As provided for by Section 3700 of the labor Code.fm the performance of the
rk far which Ni,permit is issued.
have and will maintain Workers Compeasatian Insurance,ss required by Section
labor Cade,far me performance of the work far which this permit i,issued.
Work sCompenation Insurance carrier and Policy nu'm�be'r e,m!:''nter: T� pVN fJ
Policy No.:
�
CERTIFICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE
(This section need nollWomin teed tf she permit 1,Our one hundred dollars(Sip))
or less.)
I cerOfy mat in the performance of the work far which this permit is issued,l shall rid
employ any person in any manner an As to become subject o the Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,Racy making this Ccnificam of Exemption.you should
become subject m the Worker's Compentation previsions of the labor Code,you most
=Z forthwith comply with such previsions or this permi,shall W deemed revoked.
Z .y~., CONSTRUCTION LENDING AGENCY
I hereby allifm met dere its conslmclinn lending agency far the performance of
ftwork for which this permit B issued(Sec.3197.Co.CA
Yr
Lendeh Name
3 z Lender,AM.
;)Q 1..try that 1 have and this applicahon and sum man the am.immma hue is
y correct.1 agree to comply with all city and county ordinances and mine laws relating to
Wilding construction,and hereby aonhodm represemmiws of this city to enter area the s
a above-mentioned Property for impecdon Pogeaf.
y (We)agree to saw,indemnify and keep harmless the City of Cupertino against
fA Iiatolities,judgmema,cosumd.spensns which may in anyway.ecm.egsMlwdChy
incroseguenceofthegraming uflhispermil.
C APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �zG �C13
SOURCE REG.UrIS, Q
—,J4 Re-roofs
Signature of ApplicanVComrDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will
ysapplicant or future Muni bullinge,Chapter
namor handle Health and
As defined by dre Cupertino Municipal Cade.Chaper 9.I2.and the Halm and Sefcly
Code.Sc Nan 33532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yex ❑No
Will the applicant or forum building occupant use equipment ordevicds which If a roof is installed without first obtaining an inspection,I agree to remove
in he ardnus air contaminants as dc0ned by me Bay Ama Air Quality Management all new materials for inspection.
ixvicl7 '
❑Yes ON.
1 have mad the hammousmaeriab requirements under Cheperd.95 aide e Califor.
nix Hralth&Sefery Code,Sx"..25505.35533 Ara N.Iundersend this ifthe Wilding
due,not Currently hem s terms.that it u my responsibility to unity the ace.,.I of me
mquimmem which haustj. at Lou,m is,YMCgOfa Campeau,of GCChPI / Signature of Applicant Date
/�/03
Own,,ser authonasent Dem All roof coverings to be Class"B" or better
r
CITY OF CUPERTINO 03 ,q
o cf (f
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN # CQ6 Date:
�V
Building Address:
a,O�S6 6&L= STT
Owner's Name:
Contractor: Ph ne f!c7se : -41
Hc�- w 1.-L-k- GV()) -? (o/ Z
Contact: PhCu Cupertino Business License#:
C z Gus �i, CSO ) 2-9g
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: G
Commercial
Cost of Project:
�OU
• Strapped ❑ On Platform ElBonded
11
New Location ElReplacement
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