04120061 (2) CITY OF CUPERTINO - - -_._ _..- .. .
BUILDING DIVISION PERMIT - - �CQyft"'W�TQxi INFORMATIQN - --.
BUILDING ADDRESS: - DAHL PLUMBING CO, JOHN F Phil NO. 4120061
OWNEWS NAME: PERMIT ISSUE DATE
JANET AKIN JAMES..
TONE: SANITARY OL NO.
ARCHITECr/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
LOo LICENSED CONntAC1�SPVCLARATION � JobDescri tion
uc 1 by affirm that
I am li¢nu0 uMeibro moonsof Chapu:r 9(commencing q n Description
with Scc' n 0(IU)of Dividonlo(dte BaL�ness and Professions Code,aM mYlicenu is i n `
i"f"B "d If
1. ��99ta REPLACE WATER HEATER, '7
5 i License Inc Lk.p -
�'O Date — 2 Comracmr `..
ARCHITECI•S DECOi)l- \�
�i .—�!, pMcrsund my plan shall he uud u public ?his
.0 LiccnuO Pmfcssionel
to
5 OWNER-BUILDER DECLARATION
Thereby afrom that 1 am exempt into the Comnnoes License Law for the !`�/ /, V
E no following reason.(Suction 7031.5,Business and Professions Code:Any city or county i 4 , (
m which.quires•permit to Co..,,.alter,improve.demolish,or relent,any armemou
prior An its issuurce,alw ugdues the appliant for such permit to lie a signed Stammem
that heisbanned pursuanotheprovisionsoftheConwctorilJc.ulaw(Chapter9 Sq.FL Floor Area-- Z(Lr s "/(( 'A Valua[lon
pursuant
rhe�Fm (mmmeneing with Section 7")of Divaum3 of flue Bmincs.nd Professions Code)., V
A. $ that he is exmn,I therefrom and the basis for du alleged exemption.Any violation of
Section 7031.5 W any applicant for a permit subjects the applicant to a civil penalty of 3 4421430"erO 0 Occupancy Type
not mom Nan five hundred dolly,(5500).
0 I,m mmr of the pmpeny,«my employcu wish wage u BUG sole compenuiion.
willdo the work.and the,wcture i,nut Intended«orcered forsats(see 7060,Business
Add Profession Code:The C.Wacxses U •Law dors Trot apply to an owmr of Required Inspections
p marry who Wilds«improves thereon,and who don such work himulf or through his
own employers,provided that such improvements am not Intended or offered for sale.If.
how..On,building or improvement is sold within erre year of coml the owonf-
Wilder will have the burden of proving that he did not Wild or improve for purpose of -'
ale.).
0 I,As owner of the property,am exclusively contracting with licmaed contractors W
convect the project(Sec.7064,Business and Professions Code:)The Contractor's Li.
cents Taw does raw apply man owner of property who builds or improves thereon,,rad.
who comment for such projects with a contractor(s)licensed pursuant to the Contractors
License La .
❑ I am exempt under Sec .B k P C for this usson
Owner Dau
WORKER'S COMPENSATIONDECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 love and will maintain a Cutifiauof Consent to self-intim for Worker'sCompen-
7037WrfruALaborCmm,f
ion,u provided foe by Section 3700 of the Labor Code.for the performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
or the performance of th work( ch this permit is issued.
ace Com nada.Iusuarme cvies and Pom'c r �� C/-I ate'
CERDFICAT FE)(EMPTIONFROMWORKERS'
COMPENSATION INSURANCE
(This section need not W completed ifthe pernit is ranine hundred dollars(SIM) ,
or less.)
1 certify that in the performance of the work for which this Permit is issued.l shall not .
employ any person in any manner an w m become subject to the Workers Compcnsation
Laws of California.Dam
A,oie m
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
We...subject to the Woh«'s Compcnetion Provision of the labor Code.you mew
0,Z foMwalt comply with such provisions or Nis Permit hall he d«mod revoked.
ZO CONSTRUCTION LENDING AGENCY
I heathy tl0rm that there is a construction lending agency for the performance of
C' the work f«which this permit is issued(Sec.3097,Co.C.)
IA Q Lender's NameCL
z Gander's Address
U O I ecnify dear I love,rad this...fictamn and state this the above information is
Lr.P comet.1 agree to comply with all city and county«einances and sone laws relating to
0U building conwuction,and hereby authmrim representatives of this city to enter upon the
rG above-ros j.dgraproperty forinspection Purymus.
(We)agree m save.indemnify and keep hawless the City or Cupenum against
rFiZ inconsequcdcofthe Standing of this awhich may in anyway accrue .not said City
Uz AconsequNT of the Standing of Nu Permit. Q
AP (CANT UNDERSTANDS AND WILL COMPLY W17N ALL NON-POINT Issued by: Dat
t �O-"�' Re-roofs
Signa cmf rear onwcmr �/ Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant w future Wilding occupant core or handle harasdous material
as defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Senior 23532(a)? All roofs shall be inspected nor to an roofing material beim
❑Ya p-Nt p p y g g installed.
Will the applicant or future building occu,sam use equipment or dcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it haardous air conuminanu ss defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
GYa L�Nu
1 have mad the haard ous materials requirements under Chapter 6.95 of the Califor-
nix HealthkSafctyCodu.Sections n505,25533 and M534.l undrrsund Nu ifthe Wilding
does not have a moan.that it u my msponibility m nnorY ..'an,of the
mquirc/nc c tit tprimutioranceof.cerifcatetf uancy. Signature ofApplicant Dale
L /i �y� All roof coverings to be Class "B"or better
Owner
or
nut oo'c agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
� CITY OF Fax(408)777-3333 UPEkTINO
Building Department
JO SS: PERMIT # /
�y 1
OWNER'S N PH o _ kjp
GENERAL CONTRACTOR- FAX—A
I am not using any subcontra
SignatureDO ate
Please check applicable su ontractors and complete the followinga
informtion
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
11 4F Plastering
Plumbing /Z _ �7 ,
Roofing -
Septic Tank
Sheet Metal
Sheet Rock
Tile
� e.4 '11� )- -� - C�
-�—Owner/Contractor Signature Date
CITY OF CUPERTINO Z o 6 6
WATER HEATER
Of
CUPEkTINO PERMIT APPLICATION FORM
APN # -3,1 ` S O S8 Date:
Building Address: ��
2 S W1-P ch t', a ��►
Owner's Name: / o e#: G.
ovt., e�,,+ Wl�' , -J C -f r�eo L/
-contractor: Phone: icense#: �S
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 0 Mech ❑
Job Description:
rAc -e
Residential N Commercial ❑
Cost of Proj rn Op
StrappedOn Platfo JV Bonded 13
New Location ❑ Replacement
Qty- �..
A cable Fee ID Fee Description Fee Group
BPWHEATER Water Heater I Vent BUILDING
RMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING