03090091 (2) `g CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR' NFORNINWN
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BUILDING ADDRESS: WATER HEATERS ONLY PERMITND03090091
, OWNER'S NAME: 970 E. MAIN ST, SUITE 200 PERMI17155UEDATE
RY NO.
NEI (800) 835-5946 SANITACONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i00 LICENSED CONTRACTOR'S DECLARATION JobDescri Description
U� I bemby alarm that I am limned under provisions of Chapter 9(commencing P
with Section 70Wd of Division 5 de,Bulinus dProto., Code ndmyliccnuis
', mmnmmeandeW t. G L . REPLACE WATER HEATER
'Mi Liccox fJss ` _
it-ug Date J
eq ARCH111 a DECLARATION 74513
e W U 1 understood my plans shall he used as public recnls
cat
0.1 Licenced Pmfcssinnel
�1 ,� OWNER exempt
from
DECLARATION
2 M O I hereby.(firm that I am exempt from the fession C's License Law for the .. .
1$� whIich.,reunn.(Second 7(nIS.Business and he,demli Code:Any city or county
which myuires a permit m construct,alter,imprnvc.Jcmdlieh,m repair any structure
_zy prior(.its issuance,also requires the applicant for such permit to rile a signed statement 900
that he is licensed pursuant the provisions of the Contractor's Licence Law(Charter 9 Sq. Ft. Floor Area Valuation
R`k $ (commencing with Section 7000)of Division 5 of the Business and Professions Code)or
E Net he Is exempt therefrom and the buts for the alleged exemption.Any violation of 35625025 . 00
Section 7071.5 by any applicant for apanni,subjects the applicant to a civil penalty of .APN Number Occupancy Type-- not mum the.rv.hundred dollar,(SSW). - '— P Y yP - -----
0
----
❑I.as Owner of the property,or my employees with wages a,their rale compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor:Linnen Law does not apply to an owner of 506 - GAS TE CL
property who builds or improve,doerron,and who does such work himself or through his
Own employees.provided that such improverommidenot intended moffemd impale.If. 507 — FINAL PLUMBING
however,Ne building or improvement i,sold within aneyearof OMPictian,ue Owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
,ale.).
1,as owner of me progeny,am exclusively contracting with licensed contractors to -
construct the project(Sec.7044,Business and Pmlessiuns Code:)The Contractor's I.I. .
come law does not apply to in owner or property who Wilds or improve memon,and,
who contracts for such projects with a commectorD)licensed pursuant the Contractor's
License Law.
❑l am exempt under Sec. ,B is P C for mix rtsson
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one or the following declarations: _.
I ban and will maintain a Ci nircete of Consent o ulf-imum for WorkcraCompcn-
,ation,m provided for by Section 37M of me Labor Code,for the performance of the
work for which this pmmit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
700 of the labor Code,for the performance drum work for which this pnmit is issued,
My Workerompension Insurance carrier and Polity number
am:
Cartier: F�'r�• Policy No.: L p 15'I1,
Z 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit Is for one hundred dollars($100)
or less.
I certify does in the performance of the work for which this perm It is issued,1 shall not
employ any person in any manner an a 0 become subject o the Workers'Compensation ..
Laws of Celifmnis.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cedric=of Exemption,you should
become auhjcct to the Worker's Compensation provisions of the Labor Codc,you must
7 z forthwith comply with such provisions or this perm it shall M deemed revoked.
zO CONSTRUCTION LENDING AGENCY
1 hereby of ind cont Ncre iso comtroctinn lending agency dr the performance of
Yr> in.work for which this permit is issued(Sec.3(197,Civ,C.)
QLendcr's Name
3.3.z Lender's Addmas
J Q 'I certify Net I have read this application and ante oat tic above infmmatom is
y F torten.I agree to comply with all city and county ordinances and state lawn adatingto
U building conswction,and hereby authmire representatives of trip city to enter upon the
N WM ahovamee)agremicil I.ertysave for impeni an keepha.
y (We)agree to cove,indemnify and kith harmless the City or Cupertino against
Z incofiribi idesuudgmcnts,crataintlu thisFinses
Permit, may in any wayaccroc against mid City /
U z in consequence of the Framing of this permit.
'-" APPLICANT ON STANDS AND L COMP Y WITH ALL N/ON-POINT Issued by: Dale
SOURCE REG �f III
Re-roofs
Signature or ppii� cm HAZARDOUS
M Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tic applicant or future Wiling Occupant,Chscore or handle Health an material
u dcrncd by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Code.Section 35573(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu
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 hazardous air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection.
I
❑Yes C�I have mad the haealous materials requirements umbrChapter 6.95 drum CalifonHealth h SafetyCotle,Sxdom35X15.35533 and 35574,1 understand thatiuhe Wilding
,not curmmly haw a mom,that it is my mapdnsibility m nodly the occupmt of tie
uimmcnts which mu met prig di c ora cc ' cam of,OCcupmc Signature of Applicant Date
9 n ,o
Owner oraum e am All roof coverings to be Class "B" or better
1 CITY OF CUPERTINO
WATER HEATER 03
OCUPEkTINO PERMIT APPLICATION FORM
APN#
Building Address: o—` p5, 0
Owner's Name: - G ��/•-LM Phone#:
41[
a-) 7&5
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Contyy��ctyyr: /� Phone; License #:
Lt/ ` V 530 2 7 X1-3001 -3 7-/5;7-3
Contac Phone: Q Cupertino Business License#:
7J 4-7-�
Building Permit Info
Bldg ❑ Elect ❑ Plumb Xk Mech ❑
Job Description: �q
Residential Commercial ❑
Cost of Project: G1
l 4 0 0�)
S Strapped ❑ On Platform Bonded ❑
New Location ❑ Re lacement ❑
Qty. if
A is le Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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