04080084 (2) • CITY OF CUPEWrINO 'I" ' � `� X "�* �" °# " %"'?''
BUILDING DIVISION PERMIT �'kCONTRACTOI INFORMATION, ,
BUILDING ADDRESS: PERMff NO.
04080084
OWNER'S AME: PERMIT LSSUEDATE
NE:
SANITARY O OL NO.
I
HITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'SDECLARATION JobDescri tion
sI hereby arfirm that I am licensed under provisions of Chapter 9(commencing pveeed..7")or Division Sof 0,Busixand Profcssiom Code,and my lenses �'�lClass erre"' REPLACE WATER HEATERqLE®
License adv Lie.N
L'p Dam C.nlracor
ittl ARCHITECTS DECLARATION
�i i I understand my plans shall he used as public records
SEP
A.t4 Licensed Professional
SEP 2004
=0S OWNER-BUILD ER DECLARATION
<P 1 hereby affirm Nat 1 am exempt floor Ne Contractors License Law far the
cc -following mason.(Sccuun 7831.5,Business and Professions Calc:Any city Or countyRI III DINjet
K m?6 which requires a Permit to construct.alley.improve,demolish,err repair any suuemm
m�'^ prior ar its issuance,also ma,tims the applicant for Such ,crail to rile a signed statement
=a Npursuant ntra
at he is licensedpursuanotheprovisionsoftheCoctor'sLicense,law(Chapter9 Sq. Ft. Floor Area al I
.FG (commencing with Section 7010)or Division 7 of the Business and Professions Cstle)or
i
that he o exempt tltere8om and the basis for the alleged exemption.Any violation of
&Limn 7031.5 by any applicant fur,permit subjects the applicant in-civil penalty of 38TN20**Rzr00 Occupancy Type
not mom than rive hundred dollars(SM. - r
❑I,as owner or the Prapc"Y,or my employees with wages as their sole compensation. Z tab
will do be work and the,structure is nos intended or offered for sale(See.7044.Business
and Plofeadom Code:The Coatvcmrs Lice=law does nom apply to an owner of Required Inspections
property who builds or improves thercon.ana who docssuch wan himsel(orshmugh his
Avon employees,povided thatsueh improvements arc not intended of offered for sale.If,
however,Are building or improvement is sold within one)car of completion.Are owner
builder will have one burden of proving that he did not build or improve for purpose of
sale.).
ss owner of the property am exclusively contracting with licensed contractors to
amwct the romper(Sec.7044,Business and Pafesunas Code:)The Conuacmre Li-
mmc law does not apply to an owner of property who builds or improves thcmon,and
who contracts for such Projects with a eantri ctor(s)licensed pursmnt its the Contnetors
License Law.
❑l am espmp,under So,.
.n Bh P C for this roman
Owner [O R' Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
7301.11
bare and will maintain a Ceniricut.of Consent to aelFinsum for Workers Compeer-
n,u provided for by Section 3700 of the labor Code,for the performance of the
k far which Nis permit is island.
ban and will maintain WufkOfi Compensation Imuran,u required by Section
1 ofthe labor Cade,far the performance of Lie work far which this permit is issued.
Workers Compensation Insufsnm caroler and Policy number gree
lin,: Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Nu seetinn need not beeampleted if the Permit is intone hundred dollars(5100)
ser loss.)
1 emit,Nat in the perfarmenm of do work for which this Permit is issued.I shall not
employ any person in any manner or as in become subject m the Wofolof Compensation
Laws of California.Date
A,Rcam
NOTICE TO APPLICANT:If,after making ons Ccnlacatc of Exemption,you should
bccomc subject on the,Worker's Cial,as i.n Pm Woos of Ne laMsr Code.you mw
.,O forthwith comply with such provisions err this Permit shall be deemed mvokcd.
Z to I CONSTRUCTION LENDING AGENCY
E^ lberth,asm that there is a cona.inn bodiag,gere,for the performance of
a 7 the worW
k for which this permit is issued(Sec.3097,Co.C.)
WLenders Name
d Lcndcr's Addoss
U z 2U. 1 co that 1 haveree mad this application and sato that the above information is
cortcer.1 agto comply with all city and county.Minn.x,and stateI.lrelating m
U building construction,and hereby authurile mpmanwinai ar this city to enter upon tb.
Q
0Uahovomeadaned property fa,inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F'N liabilities.judgments,costs and expemo which may in any way accrue against said City
U in consequence of the granting of this permit.
t-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI
SO I
Re-roofs
Slgnamre of Appliant/Contattor Dare ( —
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ru um building occupant start or handle hazardous mamnal
ase dcfaed by the Cupertino Municipal Cade.Chapter 9.13.and the Hcaldt and Safety
Cade.Seca..35532(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
Will the applicant or future building Occupant use cquipmero or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harafdnua air contaminants u de0ned by the Bay Arta Air Quality M..agcmcm all new materials for inspection.
cane"
C Yes ❑Nu
1 have mad the haraNaus materials requimmcnts under Chapter 6.95 or the Califor
At.Health k SafetyCodc,sections MMS.M533 and 25536.1 umicreaM thm Sick Wilding
docs not currently have a¢nam that it is my responsibility an nodfy the Occupant or dte
mgaimmentswhir:bmslbelltpramuaiy,I Cemncam.raeapancy. Signature of Applicant Date
All roof coverings to be Class "B" or better
water ser aothorimd agem Date
,- Community Development
F 10300 Torre Avenue
ate` Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
19UPERTINO
Building Department
JOB ADDRESS: ZO66 --7- Cp 2p6(NS)pF cl Ru-E PERMIT #
��s�f7Nc CA .0, (0 y4n 8 e -0 �'Y
OWNER'S NAME: (2nlT-m pA„o-,n N pAp pr=smr PHONE # c)K gs -7o
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: ` 6-eL, �
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 (1�
-� e--g' eakffX I I my
Owner/Contractor Signature Date
+•' `. Community Development `
< (/ 10300 Torre Avenue
Cupertino CA 95014
cr:;� 'N '••�
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
o
PEkTINO z.
Building D'e artment7
JOB ADDRESS: PERMIT #
G-bP�R7rNo _ n q5 r `�o ta, -44-
OWNER'S NAS: iT> da iv' A;iDE H PI-IONE # yo g eS)t 0—
GENERAL CONJ'�QC J Q : p n - FAX # a, 4 -7 j
4 III v+ r I - " /
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following.information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
d YEement Finishing
Electrical
ExcaVation
Fencing
Flooringl1 g " 'g
Ask Linoleum/,Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering / p
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock e
Tile t
Own%Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER vl o w ° `' ?�
WCUPEkT[NO PERMIT APPLICATION FORM
/ DQ
APN# `3 b Z '3 2 ate:� � v
Building Address:
20664 GA �DEN.SIDF c; 9L c CvfERrrNO CA g501
Owner's Name: Phone#:
cHI� 9An17MN CAP-PF-SH ) y09 50 070
Contractor: g Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg Elect ❑ Plumb Mech ❑
Job Description: r2EPI.AtEmev1r ar VJWJTP- h£ATFZ,
Residential Commercial ❑
Cost of Project: yos6
Strapped On Platform Bonded ❑
New Location ❑ Re lacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
�' 26 6 3
� `� ° 2-.
1
WATER HEATERS & MORE PLUMBING
P.O. Box 4358, Foster City, CA 94404 Lic. # 741904
650/525-9287 San Mateo•Redwood City `*510/477-9287 Fremont•Hayward
415/487-9287dSan,F,Eancisco^Daly City, `Z650/967-9287 Mountain View•Palo Alto
510/251-9287�Oaklana'•Berk`eley, I 4.08/229.9287 Sam Jose;•Santa Clara
i 925/685-9287 Concord•Walnut Creek 87 925/227-9287�Pleasanton•Danville {
408/229-9287,,6A229-9287,,6AGatos•Saratoga--. 41, 415/,492-92Marin!Novato
Customer Order Dater No:- ei1 ` -"` lumber f� __, z^r A # i5laninego
i e C
Sold To/BIIITo Q Order Taken By
Address Start AM
City Finish PM 1
Job Name 8 Location
Job Phone501/4 O 4i
QTY CS,7v,^ ription of Work/Mate i Is l
O
s- I
I
I
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I
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Customer will a pi for ermit, Declines to pay processing fee x l
PSI Note:PRV required over 80 P.S.I.or Warranty VoidaaD - 1
I
I I t' 1,the undersigned.owner/authorized agent of the premises listed above do hereby
authorize and pay forsaid service call/diagnosis to determine a solution.$ FEE lobe applied to
work don w. /-)
2
Signature% I11111C0 "CAf�— rl
WAVER ;Having initiated a contract in connection with emergency repairs or services for t
the immediate protection of personal property.I hereby state that the following emergency situation exists requiring
Immediate attention SEE JOB DESCRIPTION.Pursuant to section 1689.13 of the California Civil Code.I
acknowledge and hereby waive all right to cancel the sale within three days'8 to begin work listed above at the cost
Signature X
Inclutles( )Years Our Parts&Labor Warranty
Permit Fee I '
Includes ) Veers Mfgr.Tank Replacement Warranty Total Materials
Purchase Order# Total Labor
Authorization# Modifications
7
Serial# Deductible
yU r Total Amount
SignatureX /f
I hereby acknowledge the satisfactory completion of the above describe Xtp-r�Mlses
lb
have been left in a satisfactory condition.Any unpaid balances will be charg d 1,%per month(18
APR)service charge.
i