04110089 (2) CITY OF CUPERTINO �tn� n'"
BUILDING DIVISION PERMIT P3CQt�+y l�ACTOEI1�� 11
BUILDING ADDRESS: HOT WATER INC PERMIT"'54110089 -- -
10164 MANN DR
OWNER'S NAME: PERMIT ISSUE DATE
Adh SHEN YE 2531—GRACELAND AVE 1111612004
11 ONE: SANITARY NO. CONTROL NO.
650) 298-8494
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB
..MECH
epe0o LICENSED CONTRACTOR'S DECLARATION JobDescri IIOn
F 1 Mreby affirm Nal 1 son luxnud undo provivars of Chapter 9(commencing p _ ---- -
`uf iO Secrica.70M)uf Diviam Sof Oe Butinusa dProfaaahma Code.and myliccnuis
mmneClass eReec REPLACE WATER HEATER.
jyj?
License Class Lic.Y °
n-� DauContraao ,S, - -..
f AR HnEC1'g DECLARATION _ -- - - -----—
?W V I understand my plans shell be used as public=orda
6
G Licensed Pmfesional
OWNER-BUILDER DECLARATION
0 S I bunchy.(Erre that 1 1. exempt from d¢Canlns;Co Licenu Law for the
p p fallowing¢aeon. Paneth to
7(u on Business and improve,
der tau COM:Any oily of county
K$ which requires a Permit re enngron,plan improv,h Permit t fie pair any,Ifaetum
Tie Our hepoor ins iensedpalso
uant10 ata preisio of for such Penni'tOicense ned Law(Chapter
fxxp that hoeing wit pursuant10of Division
of NC Conusiness nd Podlsw(CMPur9 Sq.Ft. Floor Area Valuation - - -'
saw,
Ou(cohe
examithselfrn7and basisofroflMeed Business pion.Anynvi Code)or
- that k u eumpl Oemfrom and tK hair for sire alleged eumpuon.Any violation of
Sax,on 7031.5 by any applicant for a permit subjects the applicant m a civil penalty ofane et0 0 Occupancy Type
not mom than five hundred dollars(S50y. p y yp
❑1,u owner of the propcny,army employee wish wages ns their eats,compena0on,
will do the work and the swaure is ofirmded«offend forsale(Sec.11161,Business
and Professions Cods,The Conmemes Licen law doe,not apply to an owner of Required Inspections -
property who builds«improve thtereen,and wha doessuch w«k hi muf f or tMugb his -
own employee,provided that each improwmenu au not inmnded orolrcmd fur sals,If,
however.the building or improvement is old within one veer ofoompledon.the owner- -
builder will have the burden of proving that he did not build or improve for purpose of - - - - - -
ale.).
❑1,a owner of the propenY•am exclusively concocting with licensed comments or
conga a the pmjaet(Sec. r an Business and property
who
Code:)M Cs,thumon. rad
«sec Taw doe n«apply m an owner of protons who builds or improvrs Contractor's
oma c and /
whence contracts projects with aconuaMor(x)Iiunudpursuant to the,Conmaah - '
License Law. -
01ameaemptunder See. ,B k P C far Oil maam
Ou
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury aro of the following declggions:
I have and will maintain a Cadfevu of Conant he self-iuun for Worker's Co nKa.
radon,a Provide4 f«by Session 3700 of the Labor Code,for the pcnmma«c of the _
work for which this permit is issued.
1 have and will maintain Worker's ComPonsadon Insurance,u required by Section
37 film Labor Cade.far the peRormanee of the work for which Nis permit is issued.
My Worker',GcronPeaOminswumcconaland Polirynurnkrare:
Cartier, ty/K.(.0 rU A!r~ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed little Permit is for one hundred dollars(5100)
or Ices.)
1 canify that in the performance of one work for which this Permit is taued,I shall nm
..Ploy any parson in any manner an u to become subject o the Workcts Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifica a of Exemption,you should
become subject in the Worker's Corepcuation provisions of the Labor Code,you mug
0zMfowrm
ith comply wit such Provisions or Nis peit shall he deemed revoked.
Zy CONSTRUCTION LENDING AGENCY
F I hcrebY oRrm to ten is a eonsovainn lending agency for the Performance of
C' the work fur which this permit is issued(Sec.3097,Civ,C.)
A lender's Name
D z Under's Address
U 0 1 certify that 1 have read this application and state than the above information is
D. eorcce I ague m comply with all city and county ordinances and rum laws raging m
0 V building conwuction,and hereby authmim reocunutives of this city to enter upon too
r W abovcmemidgm psoRnY far impaction purpose:
t„�G (Ws,)agree m ave.indemnify and keep harmless Ota City of Cupcnion ageing,
y ince ses.quenc of ts.the uan of
expenses;which may in any way accroc against aid City
V z
in consequence of the grwdng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
his
SOU E gg,EGULATIO . ,/
NI�Air�,l/dc^... 0 Re-roofs
Signgure of A,,1icW OCanlrsma1 Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
u defined by the Cupenino Munidpal Cods,,Chapter 9.12,and the Health and Safcty
11-Macoda.0Y�zss3zap �No - All roofs shall be inspected prior to any roofing material being installed. _
Will the applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil hanrdous air conumicams as defied by tc Bay Ana Air Quality Managealenl all new materials for inspection.
"I
istrict' a�
0Yu LLNo
�I have toad the hvartmsresunals requirements under Chapter 6.95 of the Califon-aid ^ / -
oesnothkrentlyhamaSccdonsindit 3MY rsnd25534.1 un domed that if the building
ors not currently haw a the t thg it h my rcsponrihility m notily the scup t of
nth mug be met p o w iuuantt of a Cef4fcau of Occupanq.
� � I(/ SlgnatureofApplicant Date
Owneru autorondagent "'i— All roof coverings to be Class"B"or better
x y Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
fUPERTINO
ByRding Department
JOB ADDRESS: r l PERMrr#
�I 0oS
OWNER'S NAME: PHONE # OS ,52 -aS 2Z
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
66 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 ��f e� 11f C,
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Sam
CITY OF CUPERTINO U a
WATER HEATER d
PER T
cu RINO PERMIT APPLICATION FORM
,
APN# Date:
Building Address: 10 I/ _�
Owner's Name: (f/ u Phone #:
q , I�rn o a5/_Z -Z�ZZ
Contr o� V�/Gt (/ PUDJ( Li
d —S1 c.�CI y cs&3&/,,)—
Contact Phone: 1 t 1 Cupertino Business License#:
r6 (c< ala
Building Permit Info: /
BldgEl Elect El Plumb 2_ Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: 47
50U
• Strapped ❑ On Platform LJ Bonded ❑
New Location ❑ Replacement
,ty. if
Xppljcable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMII'FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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