05010019 (2) .. ( CITY OF CUPERTINO
BUILDING DIVISION PERMIT VCE0NI TRAqTWINF,OR�MATON--dBUILDING ADDRESS: x WATER HEATERS ONLY PERMITNLb5010019
10084 CONGRESS
NER'S NAME: PERMIT ISSUE DATE
ELEANOR TURMAN 970 E. MAIN ST, sjjj7j� 2nn 01 /04/2005
SANITARY NO. CONTROL NO.
ONE: '
(800) 835-5946
ARCHITEC iENGINEER: - BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION
y m G I hereby arrrm that I em licensed under provisions of Chapter 9(commencing Job Description -
<Z with Secuon 7003)of Division 3 ofthe Business and Palessians Code,and my lice—is
immBmreemidcB�3& WATER HEATER REPLACEMENT
z Licvnx class }� p
,gyp Dam /<nnc
i-it 2S k CH
m 1 unticrsunJ my Plans p ¢ lids .
M
Gt; Licensed Professional
OWNER-BUILDER DECLARATION
'< I Wrehy affirm that 1 am exempt from as,Convacmh License Law(of the —-- - -- - -00 following reuan.(Section 7131.5,Business and Pmfeesions Code:Any city or county -
y m which.,tires a permit m construct,alcor.improve,tlemnlish,or tepaif any swan. $800
prior to its issuance,also requires the applicant forsuch Permit o Ric a signed statement
that he is licensed punmat to the provisions of the contractor's Liccnsc Law(Chapter 9 Sq.Ft. Floor Area Valuation
QFC (commencing with section 7")of Division 3 O the Business and Professions Code)or
i that he is exempt therefrom and the buss fm the alleged exemption.Any violation of
Section 7031.5 by any applium for a permit subjects thc applicant In a civil Penalty of Ig - Occupancy Type
not mare dun five hundred dollar($5(1)). —-
I,u swore of circ propcny,ar my employers suite wags az thcv sulc wmpcnam"
o 171=
will do the work.end Ne sbucmre is notimem ed ofoRcmd forsak(Sac.'1Wa,Business
and Protestant,Code:The Comncmh License Law dors not apply to an owner of ru 0 WiLst UO Required Inspections _..
property who builds orimproves Nemon,andwho doessuch workhourelfor through his - - - - '
own employees,provided that such improvemenm are not intended orofferel formic.it, -
however.the building or improvementis sob within one ycarofemopleuon.the owner. 9 JAN Yj� L.aoo� — --------_ ___ _
Wilder will have the burden of proving that he db not build or improve for purpose of AN . .
tile.)..
co s u owner of the pfopteny,.B excessively contracting with licensedmdract is i. II II/ ®�
consumer the project IScc.elan,Business and contrasions CoticO The d count Nr's Lin tyt�I/tl('pt' .,
ce—law tloa not apply to an owner of property who Wilds ar improves Nemon,and - .
who contracts for such projects with a conaacmt(s)licensed pursuant to the Contncrnr's ,
Lice—.Law.
❑1 ran exempt under Sec. .B&P C for this..an -
Dam
WORKER'SCOMPENSATIONDECLARATION
1 hereby affirm under Penalty of perjury arc of the following decla otiose: - -
I have and will maintain aCenificem of Consent to self-insure for Worker's Compen-
rasion.u provided for by Section J9o0 of the IaWr Code,far Nc Perfannanu of the
work for which this permit isiuued.
I have and will maintain Worker's Compensation Insurance,M required by Section
T00 aide labor Code.far the performance of the work far which this permit is issued.
My Worker'sCmpensation ensu camicr and Policy number art: -
Cardcr. 5 •-4 f.-. Poliry No.:AS f)-D T V��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(3 bis section need not he completed iftha Permit is furore hundred dolbn($]W)
or less.)
1 certify Nat in to performance of the work for which this Permit is issued.I shall not
employ any persue in any manner an az in Wcome subject o the Wmkeri Compeusation
Laws of California.Dam _
Applicant .. _
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the workers Compensation provisions of Ne Labor Code,you must
,J ,z forthwith comply with such provisions or this Permit mail l be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-� I hereby affirm that there is a construction lending agency for the Performance of
C
the work for which this Permit as issued(See.3091,Co.C.)
Is7 lender's Name
z UZcr's Address
U O 1 certify that I have mad this application and sum Nal the above information is
Is. F correct.1 agree to comply with all city and county ornmareas and sum laws misting m
0U building convection,and hereby autharix representatives of this city to carer upon use
W mW.-rocmimmd property for rustication p op saes. -
�" (We)agree to save,indemnify and keep humless the City of Cupertino against
f'lig% liabilium,judgmenss,costs and expenses which may in any way sterve against said City /
U Z in consequence of the graming alibis Permit. - -
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
;Di,t,ic,l
CE REGU ATI
Re-roofs
tic onmacmr Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will cite applicant or future Wilding occupant amre or handle harardous natural
ned by the Cupertino Municipal Code.Chapter 9.12,and the Ha1N and Safety
Secuon 25532(a)1 � All roofs shall be inspected prior to any roofing material being installed.
El Y. _
Wise the applicant of future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
asafdnua air contaminants u defimcul by lie Bay Area Air Quality Management all new materials for inspection.
1 —
OYcs
In real the hasardnus macrials reyuiremcnu under Chapter 6.95 of Ne Glifor-
nu Halt&Safety Cade,Sansom 2 M5.25533 cob 21536.i undersmmtl thus if Ne Wilding -
doa rot ccommlyhese a tenarn Nat it rs my msponibility m notify the upanI of the
acquire. - mu xmetpnormi aweofaCertifiamoroFu OS Signature of Applicant Date
owner or authod..ed Ara Date - - All roof coverings to be Class "B"or better
Community Development
.c
10300 Torte Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
01PEkTINO Building Department
JOB ADDRESS: PERMIT #
iooz,4 (� v�� til 6.50 ) 0 o I q
OWNER'S NAME: PHONE # 8(os-IYSBa
GENERAL CONTRACTOR:V3-t-t�a 44atte, 1 �e, FAX #
I am not using any subcontractors: 4 oS
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ow er/Contractor Signature Date
CITY OF CUPERTINO _
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN#
Building Address:
lot>sqCoh Pl.
Owner's Name: Phone #:
EI o �e Sys- $3xza
Contractor: % , O License#: 3 VS 73
Contact: Phone#:
Applicant/ r: n I
• �S/o> 5 /23 -Z--
Building
Building Permit Info:
Bldg Elect lumb Mech
Job Descri tion:
esidential BUJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:$
�W m
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BENERGY Energy BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUHMNG
SCG 0 -2—