05030197 (2) CITY OF CUPERTINOma, an
BUILDING DIVISION PERMIT CONTRACTnR INFORMATION
BUILDING ADDRESS: PERMIT NO.
GOTITAS PROFESSIONAL PLUMB RS 05030197
OWNER'S NAME: PER M ESUE DATE
12
ONE:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0o LICENSEDCONTRACIOR'SDECLARATION Job Description
51 Mreby affirm that I am licamed under provisions of Chapter 9(commencing
R withi
Sdon TfIDB)of Division J ofdm
le Butiss and Professions Code.and my license is
R Uxer 0Choxnde6 k� �Q REPLACE WATER HEATER
5`2 z Liccnan Class Contractor
Dartlot I�TSDDECLARATION rOrYuS 5(�bGIY
7 ARCH CTS DEPURATION
I underwnJ my plans shall he used as public necnrtls
JiU
3p_ Licensed Professional
5 OWNER-BUILDER DECLARATION
.�0 0 I hereby ocam .(firm on 1 am exempt from Jw Ponlnaors e:Any c Law for the
o O following out.
a (Saran Wommo Businessand Profession Calc:Any city ar county
structure$ which mquima a permit ro cines Lha alwc improve,demolish, file
repair ed uwcwne
poor 41 in issuance.also(e[lu fC31hc applicant for such pCnllll to TIC a signed tmLL'mCnl
�1a that he is licensed pursuant w the provisions of tic Commelor's Licensc Law(Chapter 9 Sq.Ft. Floor Area Valuat on
'FC (commencing with Section 90(10)of Division 7 of the Business and Professions Code)or
W that he is cxcmpl donor om and the Was for the alleged exemption.My violation of
Section 9011.5 by any applicant for a permit subjects the applicant w a Civil penally of 3 214AUR*et0 0 Occupancy Type
not mom than five hundred dollars(3500).
❑ I.u owner of Ne property,or my employers with wages as their Sale compensation.
will the the work and the swmum u not intended or oRemA for safe(Sec.7064.Bndnw
and Professions;Code:The Conlracmfs License Law dao no,apply w an owner of Required Inspections
property who builds or improve thereon,and whereas such work himselier through his /
own employcu,provided that such improvements are not intended araRered for sale.If. L(`�
however,the building or improvement is sold within one year of completion,the owner.
Wilder will have the burden of proving that he did not build or improve for purpose of C-
sakJ.
❑1.as owner of the property,am exclusively contracting with licensed contracwm to
construct the pmject(Sec.7000,Business and Professions Cade:)The Contracwr's Li-
cense Law it=not apply ru=n owner of property who builds or improves thereon.and t]` �•�/
who contracts for such projects with a conlracmr(s)licensed pursuant w the Conuacmfs V�
License Law.
❑I am exempt under Sec. ,B&PC for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affrtm under penalty of perjury arc of Irk=fallowing declmoms:
I have and will maintain aCenifocuw of Consent to self-froom for Workcr'sCamper-
7C331.'W
ion,as provided for by Section 3700 of thc Labor Code,for the performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
of he Labor Cad,for he performance of the work for which this permit is issued.
y Worker's Compemation Immmnce carrier and Policy number amrtier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTisseclion nerd not beeomplcwd if the permit is faone hundred dollars(31010
cur less)
I certify that in be performance of the work for which this permit is issued.1 shall not
employ any Person in any mann sn talo cDDmc sub' 1 the Workers'Compensalion
Laws ofC fortyry' Dan ' i
Applicam V111t sU`MS C-,,— = " a
NOTICE TO APPLICANT:IL after making this Cenifeaw of Exemption,you should
become subject to Irk=Worker's Compcnsetion previsions of the Ichor Code,you must
.J O fo thwith comply with such pmvisiats or this permit shall bC deemed revoked.
z17 CONSTRUCTION LENDING AGENCY
Ihereby affirm that them is a construction lending agency for tM Performance of
C the work for which this permit is issued(Sec.Karl.Civ.C.)
S Q Lender's Name
Lender's nder's Address
tJ Q 1 certify tau I Mss need this application and rue don the show information is
t" correct.I agree to comply with all city and county ordinances and stale laws refiling to
0O building construction.and hemby authame representatives of Nis city to cuter upon the
W ahovcmemioned property,for inspection purposes.
(We)agree to sale,indcmmfy and keep harmless the City of Cupertino against
FrrA liabililiex,judgmenu costs and expenses which may in any way accroc against mud City -
UZ in consequence of the gaming of this permit.
^+ APPLICANT UNDERSTANDS AND W&ACOMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATI
5+ Re-roofs
Signature of Applicant/ tract - - Dole
M R US MA IALSDISCLOSURE Type of Roof
Will the applicant or uwm building occupant store or handle havardous material
as defined by the Cupertino Municipal Code,Chapter 9.12 and the Health and Safely
AmiLcalc.Section 25532(x)7 —
J�Nu" All roofs shall be inspected prior to any roofing material being Installed.❑Yet
Will me applicant or future building a«a and use e 1 or devices wmeb If a roof is installed without first obtaining an inspection,I agree to remove
rap e p gaspin
it hanrdous air contaminants a defined by thn Bay Area Air Quality Management all new materials for inspection.
uia7
❑Yes Nu
I have mad the ba cindous materials rest unomcnts under Chapter 6.95 c the Cdllfor.
nice Hcalth&Safety Cock.Sectio.25505.25533 and 25534.1 undersand shoe Irthee building
does not euem ody ha a ten a 't u my tespamibility w notify lac arupanl of the
mquimincnu hick too to issuance of a Certificate of Occupancy. Signature of Applicant � Date
All roof coverings to be Class "B" or better
Dome uth ode c ' Dov:
Community Development
F, 10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408) 777-3228
, CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB A�D�DRE • PERMIT # 0-5,6 3 p )
I QAco Mr C1,
OWNER'S NAME: yr r PHONE # pff 94 3
GENERAL CONTRACTOR: W b FAX #
I am not using any subcontractors: 3 ( 7,Z.
Sig tur Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
An 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
Owner/Contractor Signature Date
CITY OF CUPERTINO o.� 3 O( y 7
® WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN#
Date:n � 5
Building Address: Im Ll a Gte y
Co
Owner's Name: Phone #:
IsS � NOYYNq r0af 5 �or uy (e -3 3,33
Contractor: C13 P,afts5alci1 PWn ,erSPhone: License#:
amc L/-S40I �U
Contact: Phone: Cupertino Business License#:
C'
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
C.e.7a H �
Residential L3' Commercial ❑
Cost of Project:
/ , aoo
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2