05110098 (2) CITY OF CUPERTINO =" «+ e
BUILDING DIVISION PERMIT ,C,ow
BUILDING ADDRESS: WATER HEATERS ONLY PERMrr Nth.05110098
10198 MACADAM LN
OWNER'S NAME: PERMIT ISSUE DATE
ZAHRA PAVLOVIC 970 E. MA
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECVENGINEER: BUILDING PERMrr INFO
BLDG ELECTPLUMB MECH
L
3oj LICENSED CON`RACIOR'S DECLARATION Job Description
1 Woolly in.Iha(1 are licensed under provisions of Chapter 9(commencing
with Secdon 7001)of Division 3 afdt Businet and Professions Coda,and my license is
in fell force AM e rcift?� �g REPLACE WATER HEATER
Z Lieenm a—�—
Pg Divx ARCHIlW use
2 1 understand my plane shall he used u public rtcords / l,'
YOU ya red Licensed Pmfesalanal
yy
OWNER-BUILDERDECLARATIONCLARATION 'v
cos 1 hereby nHem on i am tempt from the Cssion o License law far Ile
COO (allowing moon.(section construct.
Business and Pmfnsaions Code:Any lily or county
5$ which mgWms a permit re eoruuua,alter,improve.demolish.or mpair any aumum 110
z 12 primmns Wurce,also requires de applicant Tar such pocures Lidea cense signed statement
< Nuhculkemedpot mNepmvidomafdeConuxessand nxLaw lCNplv9 Sq.Ft. Floor Area Valuation
YDS
that
ncin{with Section 7000)of Oivuian]of the BusinexeWon.AnyviCode)
amof
— that k h asempt lbemfrom and Oe basis for the allcged exemption.Any vbladan of
Semon 7031.5 by airy applicant for a permit the the appBeant W a civil penalty of r Occupancy'type
out mom dun rive hundred dollars(53001
❑I,uowverafthepmpmymmyemploymwithmSmuthebmic mpenmdom,
and Professions
Co
fte .Conus noes Llcded LAW doe set apply 70M' ma,of Required Inspections
end my wh ons Cade:Thr ves d mmfa l.delrm law am ml apply tr ru awnes is q P
procaIrwen hWpmorimPnswathmrnn,mawho ametchvert b)mxlfedifor ni his
com however.
Me a,provided thalmeh Im is mid a e et not intended Gr erortered for We.d.
but&' the have
building min of proving
did conyur of comP�oe,Ompm of
bolder w•i0 haw de burden of proWng that Ile dM cot bulb m unicorns far WRose of
cals.).
❑1.u owner of the Property.me urdum"connecting with Bemused conuamms to
construct the pmiea(See.7041.Resinm wadi Predictions Code:)The ComrnNs,Li.
comm law dm not apply to an ower of proem,+ builds or impmvn Ihemoo.and.
who contracts for adeb projects with aemluanm(s)Because incentives to der Con rWWel
L.icens Law.
Cl lameaemmunder See .BRPCfinedles o
Owner Due
WORKERS COMPENSATION DECLARATION
1 bemby air=order penalty of perjury nem of dm following decWNma
1
ha and ads maintain aCertifint of Consent m self-loom fnWortrls Camprry
salon.as provided for by Section 7700 of de labor Code.for W performance of the
work for which this permit is iamed.
I Mn and will maintain Workefs Compewtkn Insurance. rrquirton
Insurance.u d by Section ,
of cit Iain Code,for the perfermmco of the work for width this permit is Weed.
My Work(g Can cote ti=n bsmtanco emm and Policy number me:
Grtim fI�l� Policy MAIOR w4' ul7
ERTIFl CO OFATIONIEXEMPTION FROM WORKERS
COMPENSATION INSURANCE '
(Thu semen heed not be completed Ifft permit is forone hundred do0am($100)
or Wa)
I codify that in the imform ess of the well,for which Nis permit is Wood,I WWI not
c eploy any person in my mamerm as te becmmro object to the Wadv:a'Compensulon
laws of Caltfamia.Dam
APIP t
NOTICE TO APPLICANT:If,after making this GmRcou of Exmpd=n,you should
become subject on the Worker's Compensation provisions of the labor Code-You mon
O forthwith comply with such provisions or this permit]lull to demes coveted.
'y` CONTMUCr10N LENDING AGENCY
[•+ I hereby aliBm dot dorm ala coMrucOnn tending apmY far thr performanceof
G'> die wart for which this permit is Wood(Sec.3097.Civ.c)
W�0 Lender's Name
_Z Under'$Addmm
U0 1 sonify that 1 haw mW this application and tate Out dc above infam,adw is
Iy U cornett 1 a{me m comply with all city and county aNwuM
lcasale laws miming m
DSV^ building cotuuucdon,and hereby aulhodm mpmxnudvea ofthis city in enter upon cit
W show-mentioned property,for inspecdun purposes.
Ly.C (We)agree to ave,indemnify and keep harmless the City of Cuperdlm against
try Heiililies judgment.corn and upe which may In my any amus against laid City
U z in consegxn We{sand a( rmit.
.. APPLICA NDER ALL NON-POINT Issued by: DateQ—
SOUR
'1)17�O5 Re-roofs
Signanum of Appliam
nVCoaumr Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ot applicant or future building umupsmame or handle hummis matrW
IniaHed"SalmyCo�
t dellned by the Cupertino Municipal Code.Chapter 9.13^and the Health and Safely .• .
ode^Semon 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Na
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
roll hvaNnus air canuminanu m dc0ncd by the Be,Ams Nr Quality Maegemcnl' all new materials for inspection.
iavict7 /
❑Ye QNf
1 haw mad the haeuduus materials mqulmmcnu under Chapter 6.95 of the Glifar•
. dians253B3,2537J 255 . undmund thullthe Wilding
m Imlcurremly hecot.dot I m nsihlllty odfy V eccupml of Wquimmemtwhich become i t era �`)' Signature of Applicant Date
All roof coverings to be Class I'B"or better
Owner or Authorized agent Daw '
alTelCumauunily Dcvclupuicul
ephone
10300 Torre Avenue
Cupertino CA 95014(408)777-3228
CITY OF
6UPEkTINO
Building Department Fax(408)777-3333
JOB ADDRESS: PERMIT #
05110O98
OWNER'S NAME: PHONE # 7_S 2.p�Z - 2 Z
GENERAL CONTRACTOR: It O FAX #
I am not using any subcontractors:"ti,.11anjl,,.
Signature bate
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
- 11 11 a s
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 6 Date:
0/ ��� 7/c?3
Building Address: l0/
Owner's Name,.-,
Ze it- �� —Z �/ �/�
Contractor: Phone: License #:
!v F0,) 8,3.5 5956 37g573
Contact: eL. Phune: _ Cupertino Business Liccnsc #:
Building Permit Info:
Bldg ❑ Elect CSL Plumb Mech C�
Job Description:
Residential Commercial ❑
Cost of Project: !/OO
(J'D
Strapped ❑ On Platform 11 Bonded
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Description Fee Group
I BPWHEATER Water Heater/ Vent BUILDING
I PPERMITH,-F Plumbing Permit Issuance PLUMBING
l BENERGY Ener BUILDING
BUSLIC Business License BUILDING