03080147 (2) ?� CITY OF CUPERTINO N ° "r ' °," • - '«� r' P'
BUILDING DIVISION PERMIT CONTRAC,,ir )R�TNF,ORMATION
^gs BUILDING ADDRESS: HOT WATER INC PEaM"cb3080147
y
OWNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
ioo LICENSED CONTRACTOR'S DECLARATION IobDescri [ion
F I hereby affirm that 1 am licensed under provisions or Chapter 9(commencing P
.Zl auj with Section 7OrlB)of Division Sof the Business and Professions Code.md my license is
y in full rode an Beat
:8Z Lt
cena L LIc.M 0 Z REPLACE, WATER HEATER'
nF Date Cumrsclnr W
A CHITECT'SDECLAR TI N % 1
I 1 understand my plain shell W uttJ as public records r \ RED,
.
50
mucture
c o G Licensed Pndcssiond
1 3
OWNER-BUILDER
exempt
DECLARATION
2 M 0 1 hereby or Orin on 1 I.S.exempt from the Contractor's License Lew for the
5 O C following reason. arch t 71DLB.alter. and Professions h.at Any city or aunty
$ which requires s Permit m cnnswct,elree improve,Jcmallah,m repair any ntment
y prior to its issuance,also requires the applicant far such permit to rile a signed statement
Sapthat the islicensed pu ennuntheprevisionsoftheContractor'sLicenulnw(Chapter9 Sq. Ft. Floor Area Valuation
@yH (commencing with Section 7000)of Division 3 of the Business and Professimn Code)or
r, $ that M u exempt therefrom and the basis for este alleged exemption.Any violedon of 35930004 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of _APN Number. Occupancy Type
not more than bvc hundred dollen($500). -
❑1,as owner of the property,or my employees with wages as their sole compemetion, y
will do the work.and the net..is net imended or offend for 7044,Business 50Ice- FINAL 4WeC9*9RGY
and Pmfesslons Code:The Comrxmr's License law docs not apply to an owner of
property who builds or improves Narcan.and who doessuch wink himselfor through his 506 - GAS TES�TAdp
own employees,provided that such improvements arc not intended oroRcred for"Ia.If. 507 - FINAL PLUMBING
remove,the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of moving Nat M did not build or improve for purpose of
sale).
0 1,u owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70aa,Business and Professions Code:)The Contractor's LI.
mase law does not apply to an owner of property who builds or improvea daemon.and,
who coronets for such prejec0 with a centractor(d licensed punusnt to this Contrutofs
License Law.
❑l am exempt under See. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury oro of the following declarations:
1 haw and will maintain a Ceniacate of Consent to selGiasum fur Worker's Compere
sasion,as Provided for by Section 37W of the Lohse Code,for the performance of this
work for which this Permit is issued.
Rhaw and will maintain Worker's Compensation Insurance,as required by Section
3 00 of the labor Code.for the performance or the work for which this pmmit it issued.
My Wmke'J �to ✓ rier nd Policynum
Carrier. 'r a m- Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not de completed If the permit is foo e,hundred dollars($101)
or leu)
I certify Nat in the performance of to work for which this permit is issued.1 shall net
emptoy any person in try manner an as to become subject to the Workers'Co nronsatlon
Laws of Califomis.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject in the Workei s Compensation provisions of use labor Cade,you muss
forthwith comply with such Provisions or this permit shall M deemed mwked.
� CONSTRUCTION LENDING AGENCY
.22 '
1 hereby afllfm Nat Nett is a commictino lending agency for the performance of
Ys 7the.,it fur which this permit is Wood(Sec.3097,Ci,C.)
JJ—
Lender's Name
0 Lansor'sAdd. .
J 0 1 certify that I have read this application and sole that the show information is
'y curtail.I agree c comply with all uty.and county ordinances and cute hors olalin tto
mildingenniwNon,end hereby ettiome¢resses. iw of this city tocnter upon the
Wmove-mentioned to .ty fir inspection keep ca
(We)agme to raw,indemnify and keep harmless the City of Cupertino id City
yd, in
Of
cosnudof thisexpenses which may in any way accrue against mid City C ]
:.j z A APPLICANT
of UNDERSTANDS
ngof this permit y I -liG G3
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCE REGt......S. Z' /��
Signature ol'Ap"IicanV)�Cormusmr Card Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant Or future Wilding occupant store or handle hevudou material
as defined by the Cupenino Municipal Cads.Chapter 9.11,and the Hooke and Salary
oda, OYu ON.en:5533(a)7
❑ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fuwre building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havardaus air comaminanu u defined by the Bay Area Air Quality Management all new materials for inspection.
iwict7
❑Yes [3 No
I have mad the Kura d o is materials requiremenes under Chapter 6.95 of the Califor.
pia Heald,&SerctyClex.Se tions 25505.35533 and 25534.1 understand that if ft Wilding
does not currently hew a renent,that It is my rosponsihility 0 nnilfy the occupant of Ne
rcyvircmcntswhiclstW sect priarw issuance nracemrteate orocrcyf�y.�3 Signature of Applicant Date
Owner ur auNoriucJ age2nt Qz''�p kW/G All roof coverings to be Class "B"or better
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# eDate: d ✓
Building Address:
l0 COL0 a NJU-L L vJff
Owner's Name: Phon #:
&( C-4 G El-to 8A(' 27`1
Contractor: Ph e: _ C License#:
��✓/11 — �� U ZC1G 'CJY� -7(0-3&l
Contact: Ph Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: J
Residential eq Commercial ❑
Cost of Project: ��
QUO
• Strapped ❑ On.Platform ❑ Bonded ❑
New Location ❑
Replacement
Qty. if
ApplicyJA Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
# ? 2720
lr6 ?. � I