04030189 (2) CITY OF CUPERTINO _
BUILDING DIVISION PERMIT CgN'LRAC�QI2INFURMATIYQN �:.
BUILDINGADDRESS: PERMITNO
HOT WATER INC 04030189
0'106; TTMY A177,
OW NER'S NAME: PERMITISSUE DATE
JOHN
ONE: SANITARY NO. CONTROL NO.
(650) 298-' 8494
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLOC ELECT PLUMB MECH
] 0 0 0 0
yOO LICENSED CONTRACTOR'S DECLARATION lobDescri tion
1 hereby affirm that I am limosc l under previsions of Chapter 9(commencing p
n� with Scetion7")of Division 3 ofine Business road Prafusions Code.and my license,is
j� m mR fora and ercem. REPLACE WATER HEATER
� Liven lY.M
Dem Conunderstoode AHll Wtua DECLARA
Y 1 understood my pbm shall W used as Public mceomoo
da
� U
+0 LicenseO Pm(es.ionsl
OWNER-BUILDER DECLARATION
ZO I I hereby.them that 11. ucmpt s An the essins Co License Law for the
0e, following mason. ermitt Ronstr Bualass and Pe.dournns Code:Any city or county
♦ii which erqulw a pump m construct,atmq improv,demolish,or repair any structure
prior m its iuuenm,abu requites the applicant for such permit in rile a slgned summent
G that he is licensed pursuant to the provisions ofmc Comrsemr'a liceac Law(Chap=9 Sq. Ft.Floor Area Valuation
F❑$ (commencing with Section 7000)of Division 3 of the Business and Pmfesdons Cods)or
3.. mat he is exempt therefrun and me bub for the alleged exemption.Any violnion of ^Art1.i�}a�y,p
Station 7031.5 by any applicantfor a permit subjects the applicant m a civil penalty of 3 �YTIL�UWL WPir�O Occupancy Type
not more Nan five hundred dollar($500).
❑1,uowarofmepmpmy.mmyemployuswithwgcsuthebaobmmpenudm.
ME do mevock,and me,sllecturs Isnot intimated oranend lOmale(Sec.7044,Business Required Inspections
and Professions Code:The Consomme,License Law does not apply to an Owner of q p
Property who bui Ida or I m proves thereon,antl who does s uch work himself m through his
own employes,provided thatauch improvements are not Intended ora@ratl fusel.If,
however.the Wilding or improvement Is held within aro you of romplcuan,the ower. /
builder will low me Wrden of proving mat he did nm Wild or improve for pm,com at I "t
0 1,As matter of the properly am exclusively contracting with licensed contractors to , tt
consumer the project(Sec. s an Buil^^..and Profession Code:)The Canmeue.U.
come law des nototm apply ts owner of property who seddt or)mprow Conan,and - t
who contracts for such projects with aconuauor(a)licensed punuambthe Contractor's
Lkenre Law.
Olson..map,under Sca ,B&PCfar this moon
Owner Dam 1YI \ U {lJ\
WORKER'S COMPENSATION DECLARATION U
I hereby aRism under penury of perjury ane of the following declantlons:
I hew and will maintain•Certificate of Consent to self-insure for WOrkees Compcn.
sett..u provided far by Same.3700 of the Labor Code,for the,pecknons c of the
wank fm which this permit is blued.
haw and will maimein Worker's Compensation Insurance,As required by Section
of the U Wr rude.for the performance of be work for which this permit is issued.
My Workee mpemaden I^surence carticr and Policy number�S3.S 716
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thad moria need not W completed If the perm0 to form hundreddellars($100)
os leu.)
I modify that in the crimmuce of m,work for which this Permit is issued,I shall not
employ any person in any turnover An As in become subject toted Wo llmri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cedifieam of Exemption,you Could
become subject to the Workers Compensation provision.of the Leber Coda,you most
O foMwith comply with such provision.0r mi,permit.hatl be deemed revoked.
Z ti CONSTRUCTION LENDING AGENCY t
[•+ I hereby alilrm that it is a construction lendingaguxy for Cc purormura or
�i the work fm which mad permit is issued(Sce.3(0971 Civ.C.)
W�Q Lendeh Name
z Under'Address
J Q I certify that I haw mud this application and.um that the above information is
Ig,5 COMACL I agree to comply with all city and county ordinances,and sum law miming m
0 building Construction,and historyauthorise uprexmatiw of this city u COOT upon the
[27 above-mentioned property for inspection purposes.
(We)agree to sew,indemnify and keep harmless the City of Cupertino against
Mb liabilities,judgments.eau and expenses which may in any my accrue against aid City
4
V In consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINr Issued by:9 Date
SOURCE EOU
fApp1 T7 �n 0����
�m,n -1 Re-roofs
Signature of App rotor Das
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII dm AApplicant or fMuni Wilding Occupant atom mAnd the
huudoua material
stalu defined by the Cupertino Municipal Code.Chapur 9.12,end me Nrslm and Safely
ode, 0Yes 23572(.)7 All roofs shall be inspected prior to an roofing material being pros ❑Na P P Y g ginstalled.
Will me applicant or future Wilding occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haysrdoa air conumimnts As donned by me Bay Arta Air Quality Menagesmnt all new materials for inspection.
Disuin7
❑Yes ON.
I haw mal the Wadmous materials retitura mma under Chapter 6.95 of be,Califor.
rats Hulth d SafctyCade.Sections 25505.25533 and 25534.1 untlmund that if at Wilding
does not currently have a tenant,hen it b my responsibility m notify des aceupul of the
m ulremcnm which mus/ me armlaheum an eertifieam Oram Si nature ofApplicant Date
q �t DRa g All roof coverings to be Class"B" or better
Owner or awhomed gem Ut—� g
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCOF Fax(408) 777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS:/�Q6 0 O AOF PERMTT #
OWNER'S NAME: >4 f PHONE
GENERAL CONTRACTOR Wig �c FAX # (65-6 �(
I am not using any subcontractors: 03 z
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 C 6 wC.
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER ( o3
/ 97
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
5 (p -- O ( C) Date:
ct /o
Building Address: IO o uc—
Owner's Name: Phone#:
Sohn Rrn�l�s I tivs- 3 4 -?55
Contractor: Phone: 56 License#:
HOT WATjEg INC '31 — 8y9 (Z
Contact: STRIAE RO
SAN AD UNIT D Phone: Cupertino Business License#:
CARLOS, CALIFORNIA 94070
a �
Building Permit Info: /
BldgEl Elect ❑ Plumb gr Mech ❑
Job Description: (I _ 1611r—e C (1 V. _ 4E-0— Cr I .,t+C-0t „Cr
Residential Commercial F❑ T
Cost of Project:
Strapped On Platform EV Bonded
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Descri tion Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMTI'FEE Plumbin.g Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING