03110014 (2) CITY OF CUPER'fINO "?tom ler s;kt; •:�R � �."t "* r%� +
Bret-nlNc DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT N003110014
OWNER'S NAME: 170 BRANNON DR PERMITISSUEDATE
NE: (510) 376-4816 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
IOo
LICENSED CONTRACTDECLARATION
F 1 hereby affirm that I em littnud under provisions of Chapter Y(commencing Job Description
s� with Sent OM))of Division Sof Nc Bus insy}ndPm ssinns Co c, dmyliccnw is
ay
it rase ler erne _3� ✓w EPLACE WATER HEATER
>qZ License Lic.M '
Dam G.mineg; ,/� IVgLE
ARCHITECTS DEC TON
aF
I m 1 u sld.Asdad my plans shall he used asp to record. F'
n
so Licensed Pslfessional
7 OWNER-BUILOER DECLARATION
g< AffirmD`r
4 00�
I hereby arm that 1 am exempt from the Contractor's License Law for the 12003
C20 following moon.(Section 7031.5,Business and professions Code:Any city or county
<m� which requires a permit to construct,eller,improve,demolish,or repair any structure
prior to itsissuance.also requires the applicant for such permit to file a signed statement
cs that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area 'lWation
_FC (commencing wi th section 7000)of Division J of Ne Business and Professions Cattail of
Oat he is exempt therefrom and the breis for the alleged exemption.Any violaden of 32647072 . 00
Section?031.5 by any applicant for apc.if subjects the applicant I.a civil penally of , Type
not more Nan five hundred dollen(5500). '--- -APN Number Occupancy Y -----
❑ I,o owner ofthe property,or my employees with wages As their ole compensation,
will do the work,end the alructum is not intended oroRered forsalc(Sec.7040,Reainsa
and Professions Cents;The Catamount's Licens Law does not apply to an owner or Required Inspections
property who builds orimprnves themon,and who does such work himmiror through bis
own employees,provided that such improvements are not intended or offered for sale.If.
however.Ne building or improvement Is sold within one year of completion,the owner
builder will haw the burden of proving Nat he did not Wild or improve for puryosc of
sale.).
❑ h u owner of the progeny,am exclusively contracting with licensed eontrml.n t. - - --
construct the project(See 7044,Business and Profosmits Code:)The Contractor's Li.
cense Law does not apply to an owner of property who Wi Ids or improves;themon,and
who contracts for such projects with a contractor(s)licensed parstiona to Ne Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this moon ,
Owner Data
WORKER'S COMPENSATIONDECLARATION - .. -
Ihereby./farm under penalty of perjury am of Ne fallowing dedarati.m:
I have and will maintain a Ccnifcata ofConsenuo sal f-Insum for Worker's Compere ,
13:1)100.17
on,as provided for by Section 37M of the labor Code,for On performance or the
k for which this permit is issued, ,
1 have and will maintain Worker's Compensation Insurance,o required by Section
the laborCode.for Ne performanncle�e0000ff tt,(Me,work for which Nis permit is issued.
keh Cn pens.I,Io`nITnsunI�.rPf1 otic rI'ge er '!TJ gNoy3
C. 1 E F ON FROM WORKERS
COMPENSATION INSURANCE
(This section raced not he completed if the permit is for one handled dollars IS i0q)
lir IcoJ
1 comfy that in the a rrom ucc Of the work for which this permit is issued.I shall not
employ any person in any manna sal as to become subject o me Workers'Compensatinn -
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccrifcam of Exemption,you should
become mbject m the Worker'.Compensation provisions of the labor CMe,you meal
�p forthwith comply with such provisions Of Nis permit shall be deemed mamma
z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there its construction lending agency for the performance of
:4 .�-a Ne.,it fur which this permit Is issued(Sec.309E Co.C.)
31 QLeader''s Name
3wz Lender's Address
C) 1 certify Nat 1 have read this application and more that Ne above information is
y F coma.l agree 10 comply with all city and county ordinances and smm laws relating to
�U building construction.and hemby authorim representaiars of this city to enter upon the
0. atwvcmeoiml.d progeny for inspection purpmes.
r (We)agree move,iademn end kxp harmleo the City of Cupertino against
rn Iiabilitiea,judgments, and pc ma which may in anyway accroc against said City
;)7 in conscyucncc oft gr li spar 't.
'7 APPLICA L COMPLY WITH ALL NON- INT Issued by: Date
SO U S. /O
Re-roofs
Si t of Applican omrmmr pa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser future building occupant smm or handle hear mus momma)
defined by the Cupenino Municipal Codc,Chapter 9.13,and the Heallb and Safety
Cole,Section 35533(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant r future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air conmminents cfilled by the Bay Arca Air Quality Managemcm all new materials for inspection.
uviol
❑Yes
I have real a ate' bre hemenounJcr .Cha ter695ofdm Califon
ria N afct o0c, oro I5, Jan]255]0.1 unJerstvrd the ifthe Wilding
local not onl aw a sit' go ihiliiy m notify oe accupm foe
mgth. mk t t ACemficampr alt 4 Signature of Applicant Date
owner mth.riv. sent D,m All roof coverings to be Class "B" or better
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date: ' 111,41 91-V
Z6--qZ-47Z
Building Address:
Owner's Name: Ir Poe#:
ANI
O
Contractorone: �� D ig.gnse#:
Contact j4'(�G�yJP ne: Cupertino Business License#:
b,,
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped On Platform El Bonded
New Location ❑ Re lacement
QtY 1
A is e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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