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04010062 (2)crrY OF CUPEWHNo". BUILDING DIVISION PRRMIT CONTRAC�`TOR INFORMATION 6 - f R3 BUILDINGADDRESS: HOT WATER INC PERMIT NO, 04010062 OWNER'S NAME: PERMIT ISSUE DATE JAMES YGLESIA ONE: SANITARY NO. CONTROL NO, (650)298-8494 ARCHITECUENGINEER: BUILDING PERMIT INFO BLDG [CECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION - Job Description l ioneby arnfm mal I am lfilmBd under provisions of Chapter 9 (commencing with Section 7000) Division me Business and Pr fcuinnsCwc. and myli¢nm is ndP in full force and t- �s� � a IDIUGII Q Lace "S(o Lic.a ?io3ialZ WATER HEATER REPLACEMENT ARCHITECrS DECLARATION I W MAR 0 5 2004 understand my plans shall mud u public records Licensed Prnfessiunal DECLARATION Oat from 1 hereby affirm that 1 old exempt tram me Conoacmrad License Law for the I am exempt BUDLOING and Cndc:Anycity os county - whichfollowingmuma(Sanaa?nfl.Businer, star. improve, demolish, ri any structure which a permit re construct, improve, th e a sir prior m its issuance, also requires the the applicant for such permit m Glc a signet statement its Is that (ChaptersCode)9 licensed pursuant to the pro visions of dm Conoiness Sq. Ft. Floor Area Valuation Divlcion 3 of Professions me ane with Serene and Professions CsWc) or Busaged door he is im, al exempt Nm he is attempt mcmfrom and the basis for the alleged exemption. Any violation of and the Section 7031.5 by any applicant for a permit subjects Ne applicant to acivil penally of 3 B+2l9M 4i9a0 O Occupancy Type P Y YP not more man five hundred dollars (S500). 0 1, as owner mf the property, or my cmpluyeu with wages as their sale compensation, will do the work. and the stm mm is not intended oroffered for sale (Sim.?044. Business Required Inspections and Proreuims Code: The Comractors Lt.. Law dose not apply m as owner or property who builds or improves thereon, and who docasuch work himself orthmugh his own employees, provided that such improvements are not intended oroRered for ule.It, however. the building or improvement is sold within one year of completion. the owncr- builder will have the burden of paving that he did not Wild or improve for putpoae or sale.). 0 1, as owner up But racistY, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Buaim. and Professions Codc:) The Cmarutor's Li. cense Law does not apply to an owner of property who Wilds or improves thereon.and who comment for such projects with a comnctor(s) licensed pursuant to me Convenor's - Lie eel Law. 0 1 sum exempt under Sec. . B k P C for his reason Owner Date WORKER'S COMPENSATION DECLARATION 1 thereby affirm under penalty of perjury am Of the following declarations: 1 ban and will maintain a Certificate of Consent to self-insum for Workers ComWn. station, u provided for by Section 37M of the LSWr Code. for me perforname of dre work for which this permit is issued. Nl1 have and will maintain Worker's Compensation Leanne, as required by Section W of the Laban Codc. for the la formanee of the work for which this permit is issued. My Worker's CCompensation�� eremite and Policy amin arti„� "� Carrier: S 15A R F Policy No.: Lf , 9/ CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (nia sectio need not W completed if the Tcrmlt is foronc hundmd dollars (S101s) or less) 1 ecnify that in me perfomnnee of the work for which this permit is issued. I shall not employ any person in any manner so as to Wcume subject o the Workers'' Compensation - Laws of California. Date Applicant NOTICE TO APPLICANT: If, aper making this Cernficam of Exemption, you should Income subject to me Worker'a Compensation provisions of me Labor Code, you mesa forthwith comply with such provisions or this permit small W deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that mere is a convection lending agency for the performance of me work for which this permit u issued (Sec. Y . Civ. C.) traders Name Lender's Address I ecnify that I has read this application and sum mat 0m above information is ' coven. 1 ag=e to comply with all city and county ordinances and sate laws relating to Wilding commiction, and hereby aumorim representatives of this city to enter upon the abovomcntioned property for inspection purposes (We) agree to see, indemnify and keep harmless the City or Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date u SOURC EE(Gy/y.ATIONS. Re -roofs _* Type of Roof 11�1�� Signat�reood ilnt�uter HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupied store or handle havaNuus material n defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety ewe, Section 25532(a)? All roofs shall be inspected to any roofing being installed. o �Nu prior material If a roof is installed without first obtaining an inspection, I agree to remove Will mea applicant or future building occu ant use equipment or devices which pp s p Area it harardnux air contaminants as defined by the Bay Arta Air Quality Managemcm Quality all new materials for inspection. ivrict? ❑ Ycs i{(1 Na 1 have read the hnardolos�materials requirements under Chapter 6.95 of the Cxlifor. via Health K Safety Cwc. Seeman 25505,25533 and 25534.1 understand mat if me Wilding // 00 U L 0 O does not currently have a tenant that it is my reaponibility to mai ly the m pant Of the I a { regmimm sl Cl prior to issuance orfs Cerllfcam Of mpNe. SP�10hC Signature of Applicant - Date ��, C..CP �� y� 4 All roof coverings to be Class "B" or better I— Own rauthnrizw age., Dam . CITY OF CUPEkTINO CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM v�c�10�6 �-- APN # 3 / Z 6 t � Date: of o Building Address: PPERMITFEE Plumbing Permit Issuance PLUMBING Owner's Name: Phone #: M & l✓r S i L, 0 Contractor: Pho License #: Contact• Phone Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: ��,C /7%ri� Vii. 7r15O�9cfi sri Residential o= Commercial ❑ Cost of Project: -4ks oo 6� Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Re lacemen—t-Q) Qty"eff 11 DUliceble Fee ID Fee Decrrintinn Fre (:rnnn BPWHEATER Water Heater / Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING