05110112 (2) CITY OF CUPERTINO , �t�° 7P��yy'T�g+..�9'k,,Lg�' ->a ""' `�"° 1I '�'
BUILDING DIVISION PERMIT IV0,t�\Pi:"q NFURMA.T.IgN,,,,
BmLDD10 ADDRESS: BETTER WATER HEATERS PEnMITN0.05110112
10552 JOHNSON AVE
OWNER'S NAME: PERMIT MUT DATE
ALEX LEI. 351 FALCAT
NE: SANITARY NO. CONTROL NO.
(408) 250-6672
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
as
�- t� l�
j � LICENSED CONTRACTORS DECLARATION Job De r' rryyt�y
1 kroby arms Na I am ftheaari under Provisions of Chapter 9(mmmcnclag p V
with Seellon]OOU)e(DiNtlon]ofNe arithmetical Pro2�sltM, mylicense4 W�/'$7Ar
;�
inTOcaa Anda xamarg FF�� REPLACE WATER HEA'�'E�e/, 1� al ��
1 ty�z D ns C I OARCHITECr3 DECLARATIrI�N~ �/`y3 i p
pi IPrefic and my Plans shall k used u public mcorN I�j��1
s and LicensedPmfcOianal NsNQ
kN OWNER exam BUILDER DECLARATION
0 0 1 hereby,a1Rm on 1 am exempt from the Caeoamars My C taw for to
p O following mesa.Permit
in 7031.5.Business and ...moor Cade:My city or county
z� which requires a permit m ani=t L ales.Improve,damal4h.a c.sir any msture $639
z`a' that M i u kawma.res mquim ter applicant for soh permit m 0cuum Law
lCo mem
< thak4lkeued pursam to the provisionsof3Ne Cowmmrand PnolllawlChapta9 Sq.Ft.Floor Area Valuation
5p (can menciagwhh Section7000)00)1f Division de al Bed cor exacpton.My viCade)or
r3$ Nal k 4 exempt lkse(rom vb de baro for the alleged eaanptm My violation of
Section 7031.5 by any applicant fa a permit subject the applicant in a civil penalty of r U U Occupancy Type
Out more than Live hundred dollars(5300).
❑1.u owner of the pmpeM.a my wpla)cas with wga u deo mk munpeuadm,
Na n°ffe,tthe`�;Code'The c`onl�intended La ern ME a(pppiy l'�'�or Required Inspections
property who bulida or i mprovu thertan.and wk dors ouch work bianwr or amugh ilia
aweemployees,provided aarsuch improvement,am nntlnmded oroRered for aye IL
however,Ne building or improvement 4 anld within orc year efmorpkdon,ds ower-
mimor win have tic harden of proving that he did net build Or Wprma for purpose of
um.).
❑1.an owner of Na Property.am emotively contracting with accrued aomicu rs in
caulrum the prolat(Sec.]144,Baiuss and RofadOu Cade:)The ConosW'a LI-
ecce taw tau sot appy man ewes of pro aaly,wbo ha1143 or improves tenon,and,
who cadoetfa fain projects with a eontacuu(i)licenced pa ter the CoMebYl
LILCIIG Law.
❑I are esempt under S. ,B h P C for Nit ream.
ons -Data
Da
WORKER'S COMPENSATION DECLARATION
I hereby-Pum order penalty d perjury Me of the following demarulome
I have and will m-inuin a Cartfram orcouem m ulf-insm for WorkeYsCamino.
,1M.u provided for by Seton 3700 of the tabor Code.IN the performance of Na
work far which Nis permit 4 iaued.
❑1 have and will malneau
n Worte's Compmuien Omomseu. requird by Savo
3]00 of dm Labor Code•for On pe forma n e often work for which this permit is load.
My WerWlaC urian Wu artier and Polity number are:
Cartier:
CER'13FIUTT
E F E IOPoliN FROM WORKERS
COMPENSATION INSURANCE
(This salon need onlkcomPlemd if the permit 4 fare=Initiated dOm($100)
or leas.)
1 certify Not in the international of the wait fa which this permit 4 must.l ileal nor
employ any P.M.in an atyrlc rd sbT lulftwakrn'Canpenuto
Laws of CSWomi`-Bak-y
Applicant -51
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subject in the wort compensation provisions of am labor Code you moa
.,0 forthwith amply with ash provisions or Nit permit shall k dared mated.
zti CONSTRUCTION LENDING AGENCY
EI kmhyallim that Nem 4 a cououNnn lending agency for the performance of
E4
> de work for which and,pemit Is used(Sec.3097.Civ.C.)
p Lenders ame
7,Z Lessice ANddrtas
U0 i sNfy the I have red this spplleaien and mm thio de abovelefartuton 4
Ip,r". srreeL 1 agree to comply with all city and county on iuues and slam laws relating to
O SV^ Wilding m^muction.and hereby authorise rtpmm^uNu of this city to enter Open lk
{Ll above-mentoncd Property for Inspection purposes
(We)agree to save.Idemyly and kap hawks ds CITY of Caperton-90111
rrA IiWilitica dgmenu.cau and exRua which may in any my-mue against aid City
U7 in consequence of the germing M this peon.
G APPLICANT UNDERSTANDS AND WILL CO WL ALL N N-POINT Issued by: Date /2(-0 4-
4f P? �°r Re-roofs
Sipwure of�� Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantuore orkdk hazardous material
m definedby theCupera Munici ode.Chamm 9.13.and the Health and Salmy
de.Section 25532(x)] All roofs shall be inspected prior to any roofing material being installed.
❑Ya o
Will the appliest or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hmAoa air commeiunt u d by as Bay Ams Air Quality Management all new materials for inspection.
Decries?
El yes No
I have read invariant m
e hrasriW myukmnu eundarCkpmr A93afthe Califon.
nia Hulih,Sycty Code,Sedou255O5.25533a 25534.1undemtndaalfde building
does of currently hes a meant.dant It 4 my mpouildlity m Mary de naupant of the
•wa",•-a•h akmypda amaar aroaapmry. Signature Of Applicant Date
All roof coverings to be Class"B"or better
Owner or au harocul agent Dam
0D
Community Development
10300 Torre Avenue
,� I O Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPERTINO
Buildin , De artment
JOB ADDFSS: S o PERMIT#
OWNER'S NAME: A L4 c.- PHONE # o$ 2-so 16.672
GENERAL CONTRACTOR: ��r (�J�� I��n FAX # Co3 L(-"?
I am not using any subcontractors: �`s�- �✓ l l 2t 65
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
Owner/Contractor Signature Date
ZZZ�• 322 &'
CITY OF CUPERTINO
�' WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# 37s — �g c 3 s, Date: (' f O
Building Address:
10552—
Owner's
0552—
Owner's Name: L �` Pho��U • SU 8• 9 3-2-
Contract
2Contract icense #:
Contact: F:;"g S �9n _____ `OL Cupertino Business License #:
Building Permit Info:
� '�'
Bldg ❑ Elect �y Plumb Mech 21
Job Dg�cription:
Ir�z l%,, Lok 4pr �a
Residential 4 Commercial ❑
Cost of Project:4160 3 P—"
• Strapped On Platform Bonded
New Location ❑ Replacement
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