04010061 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT x C0NTRACTORINFORMATION re
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B UILDING ADDRESS: HOT WATER INC PERMIT NO04010061
iNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY N0. CONTROL N0.
ARCfIITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF-CH
_op LICENSED CONTRACTOR'S DECLARATION-
wp 1 hereby affirm thin 1 am licensed under Provisions of Chnpmr 9(enmmerism, Job Description ��_e����
iW with S.,ion]OPB)uf Divhi.a3m`am Busimseand Professions Code.and myliecnuis 'NVII
in full force and effmt
cn? ueeme elan . C— (� 're CD3 I Z WATER HEATER REPLACEMENT
,i_n Dam Contractor APR 1 .6 2004
££ A CHITECTS D[CLAR
a I understand my plans shall he used as public records
JyU
;off Licensed Professional Bu"I 'f_
g OW NERBUILDER DECLARATION I� RF1 V1
aS 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section](D 1.5,Business and Pmfcasions Code:Any city Or county
K m EL which mquires a Permit to construct,alter,improve,demolish.or repair any structum
yai prior to its issuance,also occurs the applicant for such Permit to Glc a signed statement
is that he is licensedpursuanttotheprovisionsOfJmContractorsLicxtvcLaw(Chapter9 Sq.Ft. Floor Area Valuation
YFG (commencing with Section 70(0)of Division 3Of@c Business and Professions Cn )or
iB: On,he is escmpt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of 3 4\?N3,?JaBAer0 0 Occupancy Type
not more than five hundred dollars($5W).
❑ I.as owner or the pmpeny,or my employees with wages as thei,ioddeompenadion.
will do the work,and On structure is not intended Or offered for sale(Sec.7064,Business
and Profcssiem Cade:The Contractors License Law does not apply m an owner or Required Inspections
property who builds or improves thereon.and who does such work himself tar Omagh his
sen employees,provided Nat such improvements are not intended Or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[D I.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.](l Business and Profoasiom Code:)The Contractor's Li-
cense law docs not apply to an owner Of property who Wilds or improves @inion,and
who contracts for such projects with a contracm(s)licensed Pursuance the Communes
License Law.
0 1 am exempt under Sec. .B&P C for this mason
Owner Date -
WORKER'S COMPENSATION DECLARATION
1 hereby atrium under penally of perjury one of the following declarations:
7c-
have and will maintain a Ceoi5cate of Consent to MINIMUM for WmMa'rCumpen-
n,v provided for by Station J]W of the Labor Code,for Nc performeme of the
k for which this permit is issued.
have and will maintain Worker's Compensation Insurance.as mc,dond by Section
of she LIWf Code,for the performancc of the work for which this permit is issued.
Workers Compensation Insunn¢carrier and Policy nu�mbeer�r aa(m��:55//.//IIier: T��(/wn Policy R0�.yEiRSf? k,(_
RTIFIC O OF COMPENSATION
II NPROMWWORKERS'
COMPENSATION INSURANCE
(This section reed not W completed if the Permit is for one hundred dollars IS 100)
or es.)
I unify that in the performance of the work for which this Permit u issued.I shall not
employ any person in any manner in as to become subject to the Workeni Compensation
Laws of California.Dam ,
Applicant
NOTICE TO APPLICANT:IL after making this Ceroreate of Exemption,you should
become subject to the Workers Compensation previsions of the Labor Code,you mum
.J z forthwith comply with such provisions or this Permit shall W dimmed revoked.
Z'OCONSTRUCTION LENDING AGENCY
-+
j �. I heohy affirm Nat them iso eamtruction lending gency for the Performance of
0: the work fur which this permit is issued(Sec.3(19'I.Civ.C.)
W Q Lender's Name
4 Lender's Add.
az
U Q I certify chat 1 have read this applicaion and sum that the above informatiun is
(g, F^ correct.I agree to comply with all city and county ordinances and sure laws relating to
0U building construction,and hereby aabonre representatives of this city to enter upon the
Ushove-mentioned proPcny for imPccuon puMaws.
(We)agree m save,indcmnifY and kecP harmless the City Of Cupertino against
F N Iiabilitim.judgmcnu.cons and cxpcnsu which may in any way same against said City
U in consequence of the grana ng of this Permit.
'^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EG ATI S.
Re-roofs
Signature of AppIicanUCOntracmr Daul
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding wcupam rare or handle haaardous material
as deGncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Co
de.Section zss3z(a)p All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Nu
Will the applicant or future building occupant use equipment or davices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
mricq
Yes
I havcmad NehaaNhrmaterialsrequimmenu under Chapter S.95 ofteCalifon l�
HcalN&SafetyCOde.Sectium255f15.25533and255J4.l underhand thaaifte Wilding I( /
ns not currently have a errant Nat it u my reaponsibiloy m notify 0e i cu ant of d¢ `\"`"'^^^"'���-----YYY
uimmcns mus me riortoissuance Dice Cenifmam of OccuPan
\ Signature of Applicant Dat
Owmr or authorized agent 11 Data, All roof coverings to be Class "B" or better
CITY OF CUPERTINO
sum WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
3 2- 3 0 3
Building Address:
Owner's Name: Phone #:
Contractor: P ne: _ . License#:
Contact: hone: Cupertino Business License#:
'/-Yaws G�s��N o -;73
Building Permit Info:
Bldg ❑ Elect ❑ Plumb [ Mech ❑
Job Description:
Residential ' Commercial ❑
Cost of Project:
bb
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement-(q)
Qty. if
A i able Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING .
BENERGY Ener BUILDING
BUSLIC Business License BUILDING