04050127 (2)COF CUPERTINO
DIVISION PERMIT
f
' CONTRACT,OR INFORMATION
LDITY
BUILDING
„'N
, a✓atSt �-a, `' (y. � crh9, re
BUILDING ADDRESS:
HOT WATER INC
PERMITN9047050127
OWNER'S NAME:
PERMIT LS9UE DATE
GILBERT ADAM
Ci
NE:
SANITARY NO. CONTROL NO,
(650)298-8494
ARCHITEC [ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am lieensed under provisions of Chapter 9 (commencing
with Swdon 10!10) of Division Sof IM Busiwss and Po ^.aOu Code, and my license ix
�nn
in funmoeandeffe .
REPLACE WATER HEATER
Liccn o CI y_ Llc.
Dam cmunewr
AR HDECTS DECLARATION
I my still be usual as records
JUN 7 2004
understand plans public
Licensed Professional
R DECLARATION
OWNER -BUILDER
OW
,
mOcCometa
I hereby affirm I am crept tic License law for IW
Sir
II�JII IBlgvp BlS7=J
H OING
following mason. (Section 11131.5. Business and Professions Cole: Any city Or county
ells
which requires a permit to contract, alcor, improve, demolish, or repair ,ray structure
prior m its issuswe. also requires the applicant for such March to file a signed Su¢mem
That he is licensed pursuaon mine provisions of the Comnc.r's Liecose Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 11100) of Division S of the Business and Pot entials Cook) or
that M IS exempt therefrom and de bases for She alleged exemption. Any violation of
3 fibe10 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicenno a civil penalty of
not ream Nan fisc hundred dollars (5500).
0 1, as Owner Of the property, or my employees with wages u their sato compensation.
Required Inspections
will do the work and the amactum is not intended Or offered for sale (Sec. 1(c4q Business
and Professions Code: The Contractor$ License law doer hat apply m in Owner of
property who builds or improves thereon, and who does such work himself or though his
own cmployces, provided thm such improvements are not intended Oaffered fanatic. If,
however. the building or improvement is sold within one year of completion, the owncf-
builder will bays the burden Of proving that he did not Wild or improve for purpose of
sale.).
0 1, as Owner of the inocent, am exclusively contracting with licensed contraction m
consumer the project (Sec. 7W. Business and Profusions Code:) The Consumer's Li -
ecce. law docs not apply to art owner o(poperty who Wilda or improves thereon, and
who contracts for such projects with a conaecor(s) licensed pursuant to the Contractor's
License Law.
0I am exempt on&, Sec. . B h P C for this rtuon
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby aRnm under ponalry of perjury one of tic following daclartliom:
1 have and will maintain a Certifea. of Consent to.If-imuce for Workori Comfort-
omperesuction,
suction,as provided for by Section 3100 of the Labor Code. for the performance of the
work for which Shia permit is issued.
ban and will malnuin Worker's Compensation Insunnco, az required by Section
7l of the Lauer Capt. for She peRaornee of the work for which this permit is issued.
My Workers GO evasion Insurance carrier and Policy nu b�art:
Cartiee Policy No.:
C IFICATE OF E%EMPTION FROM WO KERS'
COMPENSATION INSURANCE
('Ibis Section wed not becomplcmd if the permit is form= hundmddollars ($101)
or less)
1 comfy Our in the perfomawo of 00 work for which On pornit is issued. I shall nut
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject or the Worker a Compensation provisions of the Labor Code, you must
forthwith comply with such provisions Or Nit permit Shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
IM10aBirm Nat Nem isrnransclending agenry, far the performance of
' the wort furrwhich this permit is issued (Sec.. 3 J(191, Civ. C.)
Lenders
m..
Lenders AddAdele
j I ecrtify Nat 1 have read this application and Stats Nn the above information is
' comet. l agree to comply with all city and county ordinances and sure laws relating to
Wilding construction. and hereby authorim representatives Of Nis city to enter upon She
abovomcnlioncd property for inspccti.........
,)
IWC) agree to San, indemnify and keep harmless IM City of Cupenino against
,
j liabilities. judgments. calor and expenses which may in any way accrue against Said City
to, ...... c. of Oc granting.(,his permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dale
SOU0.CE,BEG7
Re -roofs
�J—mar. J - f_
Type of Roof — k
�$,., vCyr/'�/a'
W!
Signature of Appplimmi Contn`cor Daae
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant store or handle ha/eldous material
az dented by IW Cupertino Municipal Code. Chapter 9.11, and IM Hoaltin and Safety
Marc. Scotian 15532(a)? /
All roofs shall be inspected to any roofing material being installed.
❑Yes 7*c
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building aaupant vu equipment or devices which
mit hil.dnua air contaminanor u dcriwd by She Bay Area Air Quality Management
all new materials for inspection.
District?
0Ys Nu
I have mad the hanandousmamrials requirements under Chapmr6.95 Ofthe Calier.
ria Health& Safcty Codc, Sections 25505,25533 and 25534.1 understand Nmifthc Wilding
does not currently have a m am. that it is my responsibility m notify the cupaht of the
requirementsiissuapcearaCrohiinre�ras,ap�n�/�
Signature of Applicant Dale
�i�(/J�)(�// /
/
All roof coverings to be Class "B" or better
Owner alg.nt
ar.mar o
:CUPEkTINO
0
e
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
O
OWNER'S NAME:
PHONE # SO) (o 5
GENERAL CONTRACTOR: ,Z- 4
FAX #/�O 63 - 8Y96
I am not using any subcontractors: T �/ n
Signature Date
Please check applicable subcontractors and complete the following 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
lQ 11 aw
Owner/Contractor Signature
10/28/03
Date
CITY OF
CUPERTINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM /
APN #/` Z U V o/
Water Heater / Vent
Date: 0S 1 0L%
Building Address:
Plumbing Permit Issuance
PLUMBING
/ BENERGY
Energy
BUILDING
Owner's Name:
G i L3 Eiur fl o
Business License
Pho e #:
�1_08 2s7-339/
Contractor:
c
Pho e¢-
G�1
Li ense #:
7�310 / Z
031-9y9
Contact:
Ph e:�q
Cupertino Business License #:
GUS u.
'o %3 'ULf5
Building Permit Info:
Bldg ❑ Elect
❑ Plumb
Mech ❑
Job Description: LJ
Residential f . -
Commercial ❑
Cost of Project: -F(
Soo
Strapped ❑ On Platform
El Bonded ❑
❑
New Location Re laceme�
Qty. if
Annlicable Fee ID
Fee Descrintion
Fee Group
BPWHEATER
Water Heater / Vent
BUILDING
/ PPERMITFEE
Plumbing Permit Issuance
PLUMBING
/ BENERGY
Energy
BUILDING
BUSLIC
Business License
BUILDING
ZS 2
t