03080145 (2) CITYOf CUPERTINO
mf....NGDIVISION PERMIT ✓ ' '^'"" s'�'-+ s'v * '�' �r�r
nCONTRACTOR+INFORMATION
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BUILDING ADDRESS: HOT WATER INC
OPERMITN003080145
OWNER'S NAME: 2531 GRACELAND AVE PERMIT ISSUE DATE
l ONE' (650) 298-8494 SANITARY O. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
bop LICENSED CONTRACTOR'S DECLARATION G� O O O
s p 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
iZw with Section 700k)uf Division].(thc Bisimuomd Profcai rt Cmactiod my[fee..is
in full mrec and rt 61}lL -) 161 REPLACE WATER HEATER
L.
I s Lic.p
=Fp Date Cumnc., 0
ARCHITECTS DECLARATION
fres 1 understand my plans shall M1c used as public records
o.]aU
Licensed Professional
0
g OWNER-BUILDER DECLARATION
DECON
1 hereby affirm 1 exemptfrom the Contractor's
r's Law for Inc
0
0 following reason.(Section 7031,5.Business and u Code:Any city or county
which requires a Permit to mosso[(,all..improve,demolish,or repair any structure
pdonn its issmn¢also re e theapplillImhprormilt restatement
'hat he isliccnudpursuanu1.thpmvisinooRM1CCredoxhr's License
Laur(Chapter 9
Sq. F[. Floor Area Valuation
eFC (commencing with section 7")of Division 3 oflhe Busincm and PromationsCoam)or 32648011 00
'N9 Nm Is is exempt demfrom and de buil for the allcgcd exemption.Any violation or
Section 7031.5 by any applicant for a Permit ubjects me applicant to a civil penally of APN Number Occupancy Type
not more man Evc hundred dollars S500). - - --- --
O I,as owner of de property.or my employees with wages as Baser to compensation.
will do de work.and the sv.cxre is not intended or offered for sale(Sec.7044,Business 502 - FINAL R�+�[ JkjRc RGY
and Professions Code:The Conuacmrs License Law docs not appy to an owner of
property who builds or improves thereon,and who doessuch work himseforthrough his 506 - GAS TES
own employees.provided that such improvements are not intended or offered for sale.If, 507 - FINAL PLUMBING
however,the building or improvement s mid within one year of completion,de owner-
builder will have the burden of proving that he did not(mild or improve for purpose or
sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to —
constrain the project(Sec.70,16,Business and Protestant,Code:)The Contractor's Li. �f gI
cense Law does not apply to an owner of property who Wilds of improvm demon.andA E, FIN12
who contacts for such projects with a contractor(s)licensed pursuant to the Contu aors FINALE
12
law.
❑l am exempt under Sec. ,B A,P C for this mason FEB 12 2004
Owner Date -
WORKERS COMPENSATION DECLARATION
I heel,firma under penalty of perjury one or he following dxluations: pt��'�
I have and will maintain a CeniOcme of Consent to self-insum for Worker's Cheaper-
initial,
��I rY�
cation,as provided for by Section 3]00 of the labor Cade,for de pcanmmnm of the
work for which this permit is issued.
have and will maintain Wurkcr's Compensation Insurance,as"tried by Section
J (.1)of do labor Code.for de performance.(the work for which this permit is issued,
My Worker's C�nm nsa1[[ion��Insumntt carticr and Policy numWa�[are:(l�} rY
Cartier. S I ATfY's` Vs.l� Policy No.:
CERTIFICATE OF E%EvI Pf ION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuctinn aced act W completed if the permil u for one hundmddolless(1100)
to Ices.)
1 emify that in Bac perfamenee of do work for which its permit is bound.I shall nm
employ any permn in any manner m as or Wcome subject to root Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the lobar Cwc,you must
� O fonhwi in comply with such provisions or this Perini l shall W deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a Construction lending agency lar the a formantt of
].' de walk fur which this(amain is issued(Sec.31N7,Civ,C.)
'y Lenders Name
1 Lender's Addoss
0z
J Q 1 ttnie oat 1 have read this application and cute Nat and
above information is
.L F' building
1 agree 10 comply with all city and county ordinances and stile laws r upong m
�(J bhevc-gconmmctiacislid ly for by inspectionprposeunutivnof this city mcnmr upon do
abovo(We)Idcd pmpeny find inspection ad keep to
(s,p agree m have.indemnify and keep may
in an the City rf Cupertino against
(0.A inloide,tione ammer.or the
costs granting or hispsmit, may in any way accrue against said City
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J
SOURCE.,R�GUyAT10 5. �� ���/
Re-roofs
Signature
Date
of'AvpAc.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he appiicam or future building occupant stare or handle M1ararduus materiel
Its dc0nw by the Cupeni no Municipal Code.Chapter 9.12,and the Health and Safety
ewe.seteenzssu('» All roofs shall be inspected prior to an roofing material being installed.
plea ❑N. P P Y g g
Will the applicant or mwm Wilding occupam use equipmemor imv,I which a roof is installed without first obtaining an inspection, I agree to remove
ail WanNnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
mit'?
❑Yes F1 No
I have mad do haraNams andwrials requirements under Chapter 6.95 of Inc Califon
reitHeallhffi Safcty Cmlc,Smhrmr25505.25533and2553n.lunderslandoalifthe Wilding
dose nut ctim ntly haves cram,that is s my mspumibility w nnuly the wc.pam of de
requirements wNcn 'x/tan pr;mwi,au.ne.ora c<rdream ora.p lir./ Signature of Applicant Date
r iz"' �d �3 All roof coverings to be Class"B"or better
Owner .Feta Gard
CITY OF CUPERTINO
WATER HEATER 3
SCUPERTINO PERMIT APPLICATION FORM
APN # 0 Date:
Building Address:
0 (7" o5 2 'Avg,
Owner's Name: Phone V
Contractor: Phon License #:
J-jo f 2 r!�0 aZlB
Contact: Phone, Cupertino Business License #:
C is Gviu��� ,�o Z7B- tgyFC
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential IF Commercial ❑
Cost of Project: o J
� J
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
ApplicabFee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMffFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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