03080048 (2) ' CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTORINFORMATION.'
BUILgINcnDDREss: JANICE & FRED BOITANO PERMIrND03080048
1457 LINDY PT,
OWNER'S NAME: PERMITISSUEDATE
JANICE & FRED BOITANO 2 2003
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
tax,
O z LICENSED CONTRACTOR'S DECLARATION G� O O O
° Job Description
t� 1 hereby affirm that 1 am lirensed a Jcr provisions of Ch 9(commencing P
with Section]txxp of Division 3of NC Busi sand Professions Codc,end my license is
;c, inmllfi k*ndaffect. REPLACE WATER HEATER :B� �m��
r tR License s Lic.N
Dam —TRCHITECTS ec ARAT)ON
J lunstandindmyplans shall Mused aspublic records AUG 2 6 2003
>yU
o G Licensed Professional
S OWNER-BUILDER DECLARATION
12 a E 1 hereby affirm that I am exempt from the Contractor's License Law for the
.00 following reason.(Section]1131.5,Business and Professions Code:Any city ar county BUILDING
<S� which requires a permit In construct,slier,improve,dcmnlixh,or repair any structure $500
ofimlo its issuanm.also requires the applicant(orsuch permitter rile a signedalatement
.Z< thathcisliccnudpursuanttrnhcprovisimmofthcConlmclur''aLiecrom aw(Chapter9 Sq.Ft. Floor Area Valuation
am, morroarroming with Section 7")of Division 3 of the H ansincas and Professions Code)or 35624003 . 00
`f that he is exempt thctefman and the bums for the alleged exemption.Any violation of
Section 7031.5 by any applicantfor a permit subjects the applicant o a civil penally of APN Number Occupancy Type
not mac Nan five hundred doll..($5W).
0 1,as owner of the proper,or my employees with wages u their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7046.BusinessOC
sad Poressiona Code:The Contractor's License Law does not apply to an owner or 506 — GAS T
property,who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended oroffered for sale.If, 507 — FINAL PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
0 I,aser of the proPeny,am exclusively convecting with licensed convenors m
convect the project(Sec.7044,Business and Professions CmRu)The Contractor's Li-
cense law does not apply to an owner of property who builds or improves tbemon,and
who contracts for such projects with a contramor(s)licensed pursuant to the Contractor's
Liccnm
0l am ere funder Sec. ,B&P C for his moon
i Dam
WORKER'S COMPENSATION DE ARATION
emby affirm under penalty of perjuryo ofthe following declarations: -
1 have and will maintain a Ccnificam of Consent to self-insure for Worker's Compcn-
ation,a,provided for by section 3]00 of the labor Code.for the per(mnnance of the
work for which this permit is Issued.
❑I ban and will maintain Worker's Compensation Insurance,as required by Section
3]00 of the labor Code,for the performance or the work for which this permit is issued,
My Worker's Compensation Insurance Cartier and Policy numher are:
Ca r. P011q,tls� _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rriisscction need not beemepated if the permit Is fromm hundred dollars(SIm)
or loss.)
1 certify Nm in the perfnnna m of the work fur )�h this mit is' tied,1 shell not
employ anypgAram in yon j1 rsnuln eco pa4bjc t r —'C .tion
Laws nIC roma.De
Applicant
OT TO APPLIC A :IL after making this Ccnificam of Exemption,you should
me suhjcct m the 31 orker'e Compcnaetion provisions of the Labor Cnde,you must
.J O forthwith comply with such provisions or this permit shall he deemed revoked.
Z tiCONSTRUCTION LENDING AGENCY
'r1 I hereby affirm that there is a construction lending agency for the performance or
f1, > the work fur which this permit is issued see.7097,Civ.C.)
W QLender's Name
z Lender'sAddress
V 0 I certify that 1 ban read this application and state that the above information is
W F-1 correct.l agree to comply with all city and county ordinances and slate laws relating to
Cbuilding construction,and hereby authorim representatives of this city to enter upon the
Uabove mentioned property for inspection purposes.
(We)agree to save,indemnl fy and keep harmless the City of Cupertino against
F fn
Until lities,judgments.Costs and expenses which may in any way same against$.ad City
U z t re PPLI ANTcUoaNDEhe RSTmin ngOsthis�rWml;t.L COMPLY WITH ALL NON-POINT Issued by: Date
R
R
E
G
ULAR
Re-roofs
Si a rc of Applican om.cmr /Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant err future building uceuprod store or handle havarduus material
armed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
otic,Section 25532(e)? �Ne All roofs shall be inspected prior to any roofing material being installed.
Will the appliant n rt,uluia bn,ding«aapam sac egaipmem o;devices whim If a roof is installed without first obtaining an inspection,I.agree to remove
tit hazardous air contaminants as defined by the Bay Arca Air Quality Managcmcnl all new materials for inspection.
District?
Ycsi'u
Ihave&SafCmad the haza ns2l5O5.2JS3als irwd255umenor undcr Chapter wdffi5ofd1c Calding .
ria Health&Safety Coda Sections 2SX)5, myresnd25534.1understandthmifthehuild'mg .
dors not curtcntly ham a mnenL thm it is my rcaponsihiliry m notily tM acupmt of me
regquirements,which must be mel prior m isaoemce of a Ccnificam of acapmay - Signature of Applicant Date
0 ncrurauthoriredagcnl Date
All roof coverings to be Class "B" or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
A. All the work authorized by this permit
( B. _ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
' Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perj�that the above is true and correct. I have read and understand the
Owner-Builder Information (rederse side) (,
Property Owners Sigtature� ate:
Job Address: Permit# -
Any changes to the information provided on this form shall be submitted to the City of CnRertino Build
Devartment.
CITY OF CUPERTINO g
WATER HEATER
• CUPERTINO PERMIT APPLICATION FORM
APN# 3 P6
2 Date: Z—G
Building Address:
Owner's Name Phon
Contractor: Phone: uA1e icense#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: _
�2 �C o5 ho /
Residential PCommercial ❑
Cost of Project:
Strapped On Platform 0 Bonded Fl
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
k PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Ener BUILDING
? — BUSLIC Business License BUILDING
aa76
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