05120078 (2) AWW
FelUCILDINCI
ITY OF CUPERTINO Ia«s 'a ^,a < "s[s '-='v.��,& "Ike.a ? • ''"r `i
BUILDING DIVISION PERMIT �`�1�TRACTOR INIURriIAT�IQN:
ADDRESS: AFFORDABLE WATER HEATERS PERM"N005120078
WY
OW NEWS NAME: PERM"ISSUE DATE
TSAI, JULIA 24707 SAN FE 12/14/2005
ONE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECf(ENGINEER: BUILDING PERM"INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACnOR'SDEsmeam' lir JobDescri tion
lune 1 ionbY affirm that 1 am of the
Bu under and
Prooss ofs Cod% 9(mmmense is p
n� wlfaScoion]IXart.Division 3o(thc Busineasand Pro(casion Codc.and my license is
m mrmne anderrec � » 3bb REPLACE 50 GAL. WATER HEATER
Z Licuuc CG1
9 Dau L Conamear .'DO i
ARCHITECTS DECLAR TION
1 1 undcntsml my Plans shall be and as public recoNt
; u
Lkcnmd Pmfcuianal
�a OWNER-BUILDER DECLARATION
�s 1 bereby affirm that 1 am exempt from the Conumars Licame Law for tite `f "rtmp�lf
C O O fallowing mason.(section 7031.5,Business and Pmfeuro ioCodc:Any city or County
.j 9 t which requires a permit m caroms"a@,.improve.demolish.or mini,my structure4 Q Q
—Zi prior m its issuance,aim requires theappliaam for such permit to file a signed vemmcm
SC that heislicensedpursuanttoNcprovisionsoftheContractor'LlcensaUw(Charter9 Sq.Ft. Floor Area luation
(commencing with Section 7M)of Division 3 of the Business and Promotion Cmc)or
lS 3
than he 0 exempt therefrom and the bash far Nc alleged exemption Any violatim of
Section 703 1.5 by any applicant for a permit subjects the applicant m a civil penalty of
not mon Nan live hundred doll.,(5500). F OCC p pE
p 1.U owner of til property,or my employer with"Sea ss their sale mmpenutlon,
will do the work and the suuaum Incur Intended or affemd fornle(Sec.]ON,Business
and Profess;was Code:The Cornmeal,Livorno,Law data Trot apply m an ower of Required Inspections
pmpmy who bul c r improvca thesnon,andwha docasuch work himself or through his
Own employe,provided that such improvements arc not intended oraQered facade.if.
however,the building or improvement is sold within arc year of completion,the Owner.
builder will haus the burden of pmA.S Wt he did not build or improve far purpose of
ask.).
❑1,as Owner of the property,am exclusively contracting with lieened manometers to
contract tir pmjm(Ste.7W.Buslneu and Professions Code:)The Cmuacmfs U.
cave law dean not apply at an mnu of property who builds or improvms,menton,and
who contracts for such Projects with a canuactor(s)licensed pursuant to the Conuactors
License Law.
❑I am exempt under See ,B@P C far this reason
Owner Data '
WORKER'S COMPENSATION DECLARATION
I hereby affsmh under penalty of perjury one of the following declaration:
I ban and will maintain•Cartlfhcamor Cement tosahr-iosum for Worsues Conpen.
cation,as provided for by Section 3700 Of the labor Cade,fur the perfornarm of the
work for which this permit is hand.
❑1 Mw and will maintain WorkeYs Compensation Insurance,as required by Section
3700 of Ne Labor Cade,far the performance of the work for which Nis pcorh is issued.
My Workers Compensation Iw/seance prier and Policy number am:
Cartier.Q A'lw'f_ _. Policy Na.: — E6
CERTIFICA OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Ohtsseedm bond not W completed i(rhe permit Is foram hundred dallam($11110
or mss)
1 certify that In the performance of the work for which this Permit is issund,I shall not
employ any persan in any m nmrso as to become subject to the Workeri Compeas salon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ccnifrc.e of Exemption,you should
became subject m Ne Worker's Compensation provision,of the lalmr Code,you am
.7'O forthwith comply with such provision at thh permit shall be dmmnd revoked.
q` CONSTRUCTION LENDING AGENCY
(~ I hereby alrnm Nat then I,.construction India,a gamy for then perfonunm Or
> the work far which this permit is Issued(Sm 3097.Civ.C.)
QLenders Nam.
z finders Address
U0 I certify that I have mad this application and suis that the abe"information is
LL F context.I agree to comply with 411 city and county ordinances and sum laws minding in
OU building construction,and hereby mlorim representatives or thiscity to enter upon the
W shove-confoned property for inspection purports
(We)agree to cove,indemnity cad keep harmless the City of Cupertino against o�2 14
h.y T/1 in
equnce of ts.the grassing ex this puwhhchmryln any my Come agaiut mid City
U F77 A consequence of the RST'AN of this D WILL
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SoyRG� RNs Re-roofs
signatum of ApplicanuCanuacmr �� Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applies or fuwrc Wilding amvpant nam orhandhe h.ndous material
In darned by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
care,Scoien 25532(.)?
❑Yrs All roofs shall be inspected prior to any roofing material being installed.
Will the applicut Or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it It unions air conummanu as defend by the Bay Amo Air Quality Management 811 new materials TOT IDSpeCt10D.
pYnve u
I hamad the hssallous mauria0requircments under Chaprr6.95 of the Califor.
Ibd..
Hui"SafctyCode,Secdaro 25303,15533 and 25534.1 understand thetift he building
e,not curre he tean
nt,Nm it u my resparolhility m 1'y timw
n aupof the
,
ulcos met pormiy,arm oraccnir Orampanay. Signature of Applicant Dateuiat7 e
Owner or authorized agent ��> Data All roof coverings to be Class"B"or better
11/30/2005 10:44 66122599556 AFFORDABLE WATER HET PAGE 01/30
CITY OF CUPERTINO G) Z.-0 07�
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 3'7 Date:
/k DZ
b / 2 r p �
Building Address:
A15511 EpWoral Wv
Owner's Name: Phone#
401,
Contractor. Phone: (cle l License#
ab e o.� MR-rS aSR 713 I too 3L
Contact: Phone: to b I Cupertino,Business License#:
coiT 1 . dh O A 5 o 054 a log5b
Building Permit Info:
Bldg ❑ Elect LY Plumb f� Mech f�
Job Description:
Revlctu- 50 mien WgTer NkaT2r (SAme JaCArien
Residential Commercial Q
Cost of Project Lj 00
Strapped IJ On Platform 0 Bonded
• New Location ❑ Re lacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
! BPWHEATER Water Heater/Vent 13UMDING
PPERMI.17FEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
BUSLIC Business Llccnse BUII DING