03120073 (2) a CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON�TR'ACTORINFORMATIO
BUILDINGADDRESS: HOT WATER INC PERMIT NO.03120073
OWNER'S NAME: PERMIT I5EUE DAIS
E: SANITARY NO. CONTROL NO.
(6SO) 298- 494
ARCHOEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
U LICENSED last( CONTRd orders aiskma ATION
fCtm, Job DCSC[1 �t]-
m UUUq 1 hereby affvm Net I am limned under provisions of Chapmr Y(commencing F� ��,aR■
i with Section7(s)(BOr Division Sof NC Butmeasand Profession,C de,and my license is ��D
Lt..m cone f �p(L REPLACE WATER HEATER '
W
H?
Lomas
` Lic.N
^� rest, `°"DELL MAY 2 4 2004
ARCHITECTS....Im
DECLARATION
„Lpa e5a)and my pyna shay he used as public records
i4 Liccn ro
CS OWNER-BUILDER DECLARATION BUILDING
+�<X 1 hereby affirm that I am exempt from the Contractor's License Law for the
i
00 following reason.(Secdun 703 L5,Business and PnNeisions Code:Any city or county
which requires a permit to construct,eller,improve,demolish.or repair any structure
i< on
poorm its issuance,also requires the applicant for such permit to file a signed statement
gthat he is licensed pursuant totheprovisionsoftheContractorsLicenselsw(Chapter9 Sq. Ft. Floor Area Valuation
a (commencing with Section 71M)of Division 3 of the Business and Professions Code)or
y
that he is exempt theteffom and the basis for the alleged exemption.Any violation of nM�i Is,,
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penally of 3 HB10$IOtttlgt O 0 QCGU araC Type
not mare than five hundred dollars(5500). P Y YP
❑1,as owner of the property,or my employees with wages u their sole compensation,
will do Ne work,and the someone is notinteaded or offered for sale(Sec.7044,Business
and Profusions Code:The ConuaeDYs License Law does not apply to an owner of - Required Inspections
..it
who builds or Improves memon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or improve for purpose of
sal..). -
❑1,as owner of the property,am exclusively contracting with licensed convectors,.
construct the project(Sec.7044,Bmlness and Professions Code:)The Contractor's Li.
cense taw docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant m the Contractor's
License Law.
I am exempt under Sec. .B&P C for this mason
1371M
ner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: - -
I have and will maintain a Cenificam of Consent selGinaum for Worker's Compton.
on,az provided for by Section 3]00 of the labor Code,for the performance Of the
k for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of the Labor Code,for the performance ofthe work fur which this Permit is issued.
WONCr,Com a S.up Insurance carrier end Policylmbe,rtier. CERTIFICATE OF EXEMPTION yFROM WORKERS' �� _
COMPENSATION INSURANCE
(This section need not becomplemd irlM Permit is room,hundred dollars(SIO(n
Or less.)
1 certify thin in the informanw Of Ne work for which this permit is issued.1 shall net
employ any person in any mannerso u las become subject to the Workeri Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifcate Of Exemption,you should
become subject to the Worker's Compensation provisions Of the Lahor Code,you must
.JO fonhwi in comply with such provisions or this Permit shall be deemed invoked.
z" CONSTRUCTION LENDING AGENCY
Fa v3 1 hereby affirm that there is a eonswction lending agency for the Performance of
Rei> Ne work for which this permit is issued(Sm.3097,Co,C.)
W� Q Lender's Name
a z Lender's Address
C)Q 1 certify that 1 have mad this application mrd Stam that the above information is
w H coned.1 agree 10 comply with all city and county ordinances and state laws relating m -
QfJ building eonswction,and hereby authomve representatives of this city to enter upon the
u7 shove-mentioned property for expenses
peNon purposes
gy (Ws,)agree M save,indemnify and keep hent the City of Cupertino again.,
Cn inconsequence fthecasuand ex this Permit. may in anyway accmc against mid City
(„) A consequence of UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDSnAND WILL COMPLY WITH IAL/L/NON-POINT Issued by: Date
Signature of ApplicanJ�nracter ` / T'S p� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof _
Will the applicant or future building Occupant tors,or handle havmdous material
az de0ned by the Cupertino Municipal Code,Chapter 9.12.and Ns,Health and Safety
ode.Section 255J2(a)? All roofs shall be inspected prior to any roofing material being installed.
' ❑Yes
If a
Will the applicant or Future building omupanl use equipment Or devices which roof is installed without first obtaining an inspection,I agree to remove
.a hwuirdnux air contaminants u defined by the Bay Area Air Quality Management
strict? all new materials for inspection.
..i
C]yea (;,No
1 have mad the hasaNOussmamaaterials requirements under Chapter 6.95 of the Califor.
nu Health&Safely Cock.Smmms 25MS,25533 and 255]4.1 mulmorand that iftbe building
does not currently hove a tenant that it is my mmen.ihility,to nod ly the oucomm,of the
requiremenB whichyy.l be at pdur m issuance of a cere;fieam oPancy. Signature Of Applicant Date
!/ 1
Own
fu
e ora nerYagcm oto All roof coverings to be Class "B"or better
' CITY OF CUPERTINO
[ - WATER HEATER
i CUPE�TiNO PERMIT APPLICATION FORM
APN# 35.7 L95 05/ Date:
Building Address:
d 95
Owner's Name: Phone#:
Con ra tor: Phone: License#:
W e4 /m c . 650- 7& L5
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Ldp Mech ❑
Job Description:
Residential EjK Commercial ❑
Cost of Project:
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A lic 1 Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•