04010143 (2) CITY OF CUPERTINO
Baan NG DIVISION PERMIT ICONTRACTOR.INVORMATION. *:-
muaowcADDREss: MARTY ZIMMERMAN PERMIT"4010143
165 M12 LARRN 12L
OW NEWS NAME: PERMIT ISSUE DATE
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:00
LICENSED CONTRACTOR'S DECLARATION' — —��
1 hereby affirm that I am licensed under pmvixions of Chapter 9(commencing escrlptlon o
z1� with Scnion]O(10)ar Divixion3of he Business and Pmfcninns Code.entl myliccme is
in mumrenoadAReet. REPLACE WATER HEATER
n�et License Class Loc.r SFp
yap DaR Contractor _
¢¢ ARCHITECTS DECLARATION
1 understand my plans shall be used as puhlic records
Diou 801
it
0<
vhi Licensed Pmressional
in
� 3 thatOWNER-BUILDER DECLARATION
<S I masa affirm on?1 1. exempt from the Contractor's License Law for the
00 which
following on.(Section]misumt. too,
ver demolish.
h.or re tri city nr county
1:0
so which squires a issuance,
construe,alkn imforsu demolish m repair sir any moment
_Za retthat hec itsiensedprsuant to the the
ovisioso the Conpermitmicense Law
rt
at (emmiimmgwidpuntle.7 )ofDivision3ohceBawoss.ccarefenn (Chapter Sq. Ft. Floor Area Valuation
yt$ that he
exemit thereioah And (Division]ortheegedoxsand Professions O�Jc)or
y 3 Jeal he is exempt Ihertlrom and Ne basis for the alleged exemption.Any=of ��,�ro1�.��M1aT��rr,,,¢di.,
Section 703 15 by any applicant for apnult subjects the applicant to a civil penalty of 314adw dOct)0 Occupancy e
not marc man fire hundred do0an(S50y. P YTYP
A1 1.as owner of the pmpany,or my employees with wages as their sole compensation,
will do the work and the awcoure is not intended or offered finale(Sec.7044,Business
and Professions Cade:The Contractor's License Taw does not apply to An owner of Required Inspections
podiatry who builds or improves theremi,nd who doessuch work himself or through his -
own employees,provided that each improvements are not intended oroffered fureale,If.
however.the building or improvement is sold within one year of completion,the owner-
builder will have Ne burden of proving Nat he did not build or improve for purpose of
soled.
❑I,as owner or she property,am exclusively contracting with licensed contractors to
construct the pmjecl(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of property who builds or improves hereon,and,
who contracts for such projects with a contnnor(s)licensed pumuantto the Comractdfa
Liz)eaze Law.
011 ams pt, order Sec. ,B&P C for his moon
Owner 4 Data
MPENSATION DECLARATION
I here der penally of perjury one of the following declarations:
I haw and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation,As provided for by Section 3]IXs of me Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
3100 of the labor Code.for the performance of the work for which this pamcit is issued.
My Worker's Compenwrion Insumme carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not M completed if the permil is for one hundred dollen ISI(K))
or iced) I '
1 cattily that in the parfnsmance of the work for which this Permit is issued,I shall not
employ any parson in any mannerso As In become subject o the WorkerCompensation
Laws of California.Date ,
Applicata
NOTICE TO APPLICANT.If,After making his Cen ne.t.or Exemption.You should
become auhject m the Worker's Cm,cmmion wovosomn of the Labor Coda.you..At
.JO forthwith comply with...h pmviainns m this permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[—i tis Ihereby affirm that there is a construction lending agency for the performance of —
CL the work for which this permit is issued sad.3091,CO,C.)
QLender's Name
D
z LcMcr'x Address .
U Q I certify that I have read this application and ante hal the slow information is
ty correct,I agree to comply with all city and county ordinances and suite laws relating to -
QU building construction,and hereby authorize reprcaenmlws of this city to enter upon the
6Wi
Above-mentioned property for impaction enses purposes.
(We)agree to save,indcmni ry and keep hrtmless the City of Cupenhm against
cF.cZ in
equncejudgments,the gralaing expenses which may inany way accred egeina'set dCity
U `L A F`Llquencc of he granting of his permit.
APPL NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 ONS.
t i Gy Re-roofs
Sign urcofA ca 'motor D c
Z RDOUS MATERIALS DISCLOSURE Type Of ROOF
Will Mot
farm building occupamemre or handle hazardous mamrud
As defined by l Arco".Municipal Code.Chapter 9.12,and the Health and Safely
Imqu
e,Section 25532(e)? All roofs shall be inspected prior to an roofing material beim
❑Yds P P Y $ g installed.
Will the applicant or future building occap re dee equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as d fined by the Bay Area Air Quality Management all new materials for inspection.
bicr?
❑Yes ;1-
_1
hew read the hazardous materials requirements under Chapter 6.95 of the Califon
Hcal or&Safc yCoda,Sano.255(15,25533 and 25534.1 atimmmnd the if Sir holding
t vnen11 hraw ich mu at be mel prior to issuance or a Canircate OccupancySignature of Applicant Date
t 3e 04ner ar dam sed ".ala All roof coverings to be Class "B" or better
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# � ( �T 2 i 0 5 Date.
� 1 3,olo`t
Building Address:
os rnt_R�Rc,,,J pLAcf � CdeFP-,T+ uo, C•,A a5014
Owner's N/�a,iIm� : y Phone#:
N
Contractor: Phone: License#:
S£�f
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential )R Commercial ❑
Cost of Project:
2'00
Strapped ❑ On Platform ❑ Bonded ❑
• New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING