05040058 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRA.CTOR INFORMATIQN: :'
BUILDING ADDRESS: PERMIT NO„5 Q 4 0 O 5 8
' OWNER'S NAME: PERMIT WOE DATE
ONE: SANITARY 0. OLNO.
ARCHITECVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMR MECH
uoo
LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affnn Ihei I am licensed under provisions of Chapter 9(commencing
b with Sceuon7"rr"f Division 3oflhc Business and Professions Code,and my license is
in full tome and cffm
q= Lie,mcOaza see.. REPLACE WATER HEATER /
qq ARCHITECTS DECLARATION CSL
�2< 1 understand my plans shall W used a public records
Ddu J/�
3 u Licensed Professional
+03 Oat lam exempt
UILDER mptfrm Ce Copor ON
S 0 1 hereby.(Tim on 1 am cxcmpt from the Canteaaaod License law for the
p O following mason. arch t 7(13 1.3,Business and vet&--fi Codc:Any city at county
m which requires a e.also m,dreus a alter.impmw,demolish,nr r a sigmy tmcmw
Fieprior mint issuance.also sequins We applicant for such Permit tilt asigneJ statement
x
that he is licensed pursuant to the provisions of the Contactors License Law(Core,9 Sq.Ft. Floor Area ValUa[IO
or a (commencing with Section]000)of Division 3 of the Business and Professions Code)or
a, that he nt exempt therefrom and We,bait for the Jlegcd exemption.Any violation of
Section 7031.5 by any applicant far a Permit subject Ne applicant to a civil penalty of 3g, Nq t *grpp Occupancy Type
not mom Nan five hundred dollars(S50)).
❑I,as owner of the propcny,or my employees with wages as their core compensation,
will do We work,and We suucmre is not intended or offered for sale(Sec.7)44,Business
and Professions Cade:The Coneracrer's License Law does not apply a an owner of Required Inspections
proprn y who builds or i reproves Uemon,and who docs such work himself or through his
ownemployces,provided that such improvement art not intended or offered for sale.11.
however.We building or improvement is sold within coo yea of completion.We owner-
builder will have We burden of proving Nat he did not Wild or improve for purpose of
sath.).
❑1,as owner of We prnpeny,am exclusively contracting with licensed Contractors m
Couturier We pmject(Sec.71)64,Business and protrusions Code:)The Contracmr's Li
nse law dors not apply in an owner of pmpeny who Wilds or improves domon,and
who contracts for such projects with a co..,o,(,)licensed pursuant to that Contractor's
License law.
❑I am exempt under Sec. B A P C for Of,mown
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
1 bare and will maintain aCenifieate of Consent to self-iaum for Worker'a Compen-
sation,as provided for by Section 37W of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,az required by Section .
3]W of the Labor Code,for the performance of We work for which this permit is modet.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecomplcted if the Permit is for one hundred dollars(SIM)
or less.)
I Conify than in the performance of the work for which this permit is issued,I shall req
employ any parson in any manner sex as m become aubjWL 10 the Workers Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the tabor Code,you must
.�Z forthwith comply with such provisions or this permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-. I hereby affirm Nat Were is a constrosonn lending agency for the performance of
a the work for which Nis permit is issued(Sec.3097,Civ.C.)
alender's Namc
,7 Z Lender's Add=
V Q t cenify Net 1 have read this application and trot Nat the a arvs information Is
Ix,f" correct 1 agree to comply with all city and county ordinances and ala¢laws terming to
O V Wilding construction,and hereby auNodm mpfucmatiwx of this city to(Witter upon We
r W abave-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
i req liabilities,judgments.count and erre swhich may in any way act..gainst said City
V z his Permit,
APPLICeUNDERSTANDSof the granting of t
ANTAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanVCom Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We of forumbuilding
e.Charwomor handle Heallousmaterial
az degsed by de Cupertino Municipal Codc.Chapter 9.13,and We Health and Story
Cwk,Section 25573(a)?
❑Yes 0 N All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
1 have mad the hon dour materials requirements under ChapOr6.95 of the Cable,
M.Hwlth&Safe,Cude,Sccdou35505.35533 and 25534.1undersand rhaifthe Wilding
data not eunendy haw a tenant Na it is my msponsibility b notify the oaupant of the
requiwmentawhich Fund the met poor toituanaofaeemfieateofOccupancy. Signature of Applicant Date
0wner or authoriacd agent Doth All roof coverings to be Class "B"or better
� CITY OF CUPERTINO
WATER HEATER �OoS�
CUPERTINO PERMIT APPLICATION FORM
APN# .361 3 0 ZZ Date:
Building Address:
z031-7 den,
Owner's Name: Phone#:
//dP-zS5-81910
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumbzi Mech ❑
Job Description:
Re,q(a.ce LA)a r- L-ea, ea-
Residential [ Commercial ❑
Cost of Project:
Strapped On Platform �j Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BPWHEATER Water Heater/ Vent BUILDING
PPERmrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING