05050060 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT WONTRA"6T 0 RwINFORMATION',c
BUILDING ADDRESS: NATIONAL ROOTER PE"'NG05050060
4rr T.TMDA AMM CM
OWNER'S NAME: PERMTTIBSUEDATE
AW
ONE:
SANITARY 0. CONTROL NO.
(40BJ 241 -088:Z
ARCHITECryENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
m I hereby antro Out 1 am licensed under provisions of Chapter 9(commencing _ Job Description
3iW wu,'t ii on 1IX10)af Division NC Business and Professions Cock.and myliccnu is �I����®
men rnreeam err« P_3� 3 O REPLACE WATER HEATER
L Z in u Cl�sr Lk.M
Dale Crimoebr
FF ARCHITECTS DECLARATION
?C U 1 understand my plans shall be used az public records �, ZOO5
;Q� Licensed Professional
Z`o3 OWNER-BUILDER DECLARATION
Y 1 hereby affirm than room am exempt m the Conlranoh License Law for IW Egilk
O O following mason.(Section 11D L5.Business and Pmfecsimu Cade:Any city or county
K m which requires a permit to cin t,alter,improve,dcmnlLsh,m.,it any structure
prior to its issuance.also requites the applicant for such Permit to rile a signed samment
—�< thatW is licenxJ purmanuo the provisions of Ne Conuacmr's License law(Chapmr9 Sq. Ft. Floor Area -Valt1hflW
'r--O (commencing with Section 1000)of Division J of the Business and Professions Critic)or
y
that he is exempt therefrom and the basis for the alleged exemption.Any viand
on of
Section 1031.5 by any applicant for a permit scbjcw the applicant to a civil penalty of 3 2VV3T`WbV0 0 Occupancy Type
not mom than five hundred dollars(5500).
I,u owmr of the pmpeny,m my employcm with wages u their mie compenution,
will do the work,and the awcture is notimended ordRemd torsade(Sec.7004,Business.
and[impressions Code:The ConerxctaYs License law does not apply m an owner of Requiied'Inspections
property who builds or improves lbemam,and who does such work himself or Nmugh his
awn employcce,provided that such improvements art not intended aroRered for tile.If.
however.the building or improvement is sold within one year of completion.Ne owner-
Witter will have the burden of proving that he did not Wild or improve for purpose of
.I,)
❑I,as owner of Ne progeny,am exclusively contracting with licensed contractors to
consumer Ne pmjccr(Sec.1D04,Business and Professions Cade:)The Connamri Li ,
creme law does not apply to an owner of property who Wilds or improve Ncmon,and
who com acs for such projects with a commetor(s)licensed pursuant to the Contractors
License Law.
1 oro exempt under Sec. .B&P C for this mazon
Owns, Dal
WORKER'S COMPENSATION DECLARATION
1 hereby alfmm under pearly of perjury ane of the following declastimoc
I have and will maintain a Cartifrnm of Consent be self-insum rot Wmhcls Compen-
sation,u provided for by Section 3100 of the Labor Code.far Ne performance of the
work for which this permit is notice.
1 have and will maintain Worker's Compensation Insurance,az required by Section
3100 of Ne labor Code,for the performance of the work for which this permit is issued.
My work s/sC/nmprown aumncc carrier and Policy number are:
Cannier. a o n Policy No.: OD�D��g-2 4
ERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(Thu scrim need not becomocied if the Permit is foronchundmd dollars(5100)
or less.)
1 ccmfv that in the performance or dm work for which this permit is issued,I sball not
employ any person in any manner so ta to become subject to the Workcmi Compensation
Laws of California.Dao:
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compcnurion previsions or the Later Code.you must
.J Z fortbwith comply with such provisions or Nis permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-. 1 hereby alfnm Nat then is a cumumc,ion lending agency rot tha performance of
!Yi 7 the work(m which this .it is issued(Sec.309'/.Civ.C.)
Under'a Namc
=z lenders Address -
U C 1 cenify Net I have read this application and sum that the above infamlatiuo is
H correct.l agree in comply with all city and county onlioarmes and sum laws relating to
0 building convection,and hereby authorize repreunatives of this city to enter upon the
Y' about-mentioned property for inspection purposes.
4. (We)agree to save,indemnify and keep hemleo IW City of Common againsl
F"h liabilities,judgments,costs and expenses which may in any way seem=against said City
U z' ethis
permit.
APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: DateJf&-J•-
SOURCE, , ATIONS.
tCN limo/� S/%tit— Re-roofs u
Signa of AppliamlC nun Ho Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle hvudous material
az defined by do,Cupertlao Municipal Code.Chapter 9.12.and the Health and Safety
Gale.Safea 2'
❑veer 532(a)7 14". All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it baurJnus air cnmuminans as defined by the Bay Area Air Quality Managcmam - all new materials for Inspection.
istric,7
❑Y., V
1 have mat the haaardims materials mquimmcnu under Chapter 6.95 or the Cali Let-
ma Health&Safety Code,Sections 25515.25533 and 25534.1 umdemanal this i(ho Wilding
does not currently have a mnank Nat it u my responsibility to rmtify the aeupsm of the
reytore ch most be met or m iss of a Cenifcam of Occupancy. -
S �q' Signature of Applicant Date
Ow oratomindas agent Dam All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: G PHONE
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: �& S
Signature Date
Please check applicable subcontractors and complete the followin information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
C. 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
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# Z b Date:
s-/
f 3 " � s-/i--os-
Building Address:
Owner's Name: Phone#:
cS7
Contrac or: Phone: License#:
��ro �4 7'v8 �Y/ O 7 �G�3oo
Contact: Phone: Cupertino Business License #:
a.� . 2 0 8R 7
Building Permit Info:
Bldg Elect ❑ Plumb E�— Mech ❑
Job Description: 7
Residential D Commercial ❑
Cost of Project:
vb�-
Strapped Ja On Platform ElBonded
New Location ElReplacement
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
2� 6 �s �