06020097 (2) CITY OF CUPERTINO
777777 ^�
BUILDING DIVISION PERMIT CONRACT+OR TNFQ7.tMATt()N `�
BUILDINGADDRESS: WATER HEATERS ONLY PERMTTNO.06 02 0097
21337 METEOR DR
OWNER'S NAME: PERMITISUEDATE
CATHY CROWLY 970 E. MAIN ST SUITE 200 02/15/2006
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECTIENGINEER: BUILDING PERMITINFO
UMB MECH
h):r A e�c� ��. PLO O
�0z LICENSED CONTRACTOR'S DECLARATION
If. 4/ "4 ! r4 a
reUm 1 Wroby affirm that l am liamed under previsions of Chapter 9(commencing JO b serlpuoni'�"' f( r1,aM d/
n< with Section 70,11)of Divixlon 3 of the Business and Professions Code,and my licenmb �^"ffi'
�<' Lfullfo¢eondcff--� �7V-S77 REPLACE WATER HEATER
= License Lie.« APR 2005
n t• Date Cmom m
yj< IundcrtanJ my ARC �bl
g u.U Licensed Professionalt
g OWNER-BUILDER DECLARATION f
9 i Y I hereby affirm that I am exempt from the Contractors License Law far the
OO following reason.(Section 70313.Business and Professions Caw:Any city or county
C
S which squirm•Permit m ennarom,slur.improve,demolish.or repair any stmetum $1000
4;- prior in its isamme.alsuuquima tiro applitanl reattach permit wfik.u1ned suterm.,
< thatW I.licensed purwanlm the previsiansof da Contractors) ac law(Clnpter9 Sq.FC Floor Area Valuation
x�$ (eammencingwide Section7000)of Division3ofrhe Busirewand Pmfessinm Code)ur
that he is exempt dtemfrom and the basis for the alleged exemption.My violation of
Sermon 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of 3M r V L Occupancy Type
.or mere was five hundred dollars(5500).
❑I.as owner of the property,a my employees with wages u their sole campensadan,
will do the work and the structure is not intended or offered for sale(Sm.70114,Business Re uired Ins ections
and Professions Calc:The Contractors Liam.law does ret apply m in owner of q p
property who buildsar lmpeae,thereon,add whodoessuehwork himsef orthrough his
own employ=,provided that such improvements K not intended oraaered for We.If,
however.the building or improvement Is mid within one year of completion,the owner•
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1.es owner of the property,am exclusively contracting with licensed contractors in
comtmet the project(Sec.7004.Business and Profession Cade:)The Continues Li.
came law dam not apply in an owner of property who Wilda or improves thereon.and,
who contracts for such pmjecu with a conhacmr(s)licensed pursuant in the Contractor.
License UW.
❑1 em exempt under Sec. .B k P C for this reawn
Owner Dee
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declintions:
I bsve and will maintain a Certificate ofCensent m self-insure faworkeM1Compen-
sauan,as provided for by Section 37M of dte labor Code,fa the p doonma of that
wart for which this permit Is issued.
1 have and will maintain Waters Compensation Insurance,sa required by Section
3700of the labor Code.for the performance of the wok for which this permit is issued.
My Wor s mpemodanI u e 'e and Policy n1umber tee
Carrie,' aa1�` Policy No.:T6-0 -3-0y 1 p
C RTIFl TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This motion need not W complcwd If the permit is fmane hundred dollen($100)
or Iona)
1 candy that In we performance of the work for which this permit Is issued.l shall not
employ any pence In any mannerm u In becomembject lithe Workers'Compemadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,aAct making this Ccnifreaw of Exemption,you shouse
become abject to the WorkeM1 Compensation provisions of the Unto Cade,you must
wJ O forthwith comply with such provisions or this permit shat be damcei rooked.
Z'••' CONSTRUCTION LENDING AGENCY
[ti o-5+ I hereby station construction them is aconstruction wading agency for tee performance of
0.S> the work fa which this permit is lama(Sec.3U97,Cr.C.) .
a q Lenders Name
Z Address,
Addre
U0 I certify that 1 have read this application ad sate Nn the am.information is
w P corrin I agree w comply with all city and county ordinances and slow laws misting to
O U Wilding construction.and hereby audente reprommatives of this city to error upon the
157 .hove-memioned property for Inspection purposes
O. (We)agree in save,indemnify and keep harmless the City of Cupertino against
nes 5
liabilities,Judgments.emu andexpensm which may in any my accrete against aid City
(„) in consequence of the lending of this rmiI.
APPLICANT DERSTA S WILL C PLY Y/ITH ALL gON-POINT Issued by: Date
� /ffJ�� C
SOURCE R LAT / "S/O
Re-roofs
Signature ofApplicaVCanDau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Co e,Chaptamm or handle Health
sd Safety u defined by the Cupertino Municipal Coo.Chapter 9.13,and the Health end Safety
ado Section 15532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yet mlu_
Will the appneam or future building occupant use equipment at dcvwm which If a roof is installed without first obtaining an inspection,I agree to remove
B handous air contaminants as de0md by to Bay Area Air Quality Management - all new materials for inspection.
Oiarin? � ''
❑Yea pywui_
I have road the haardma materials requirements mulcochapter 6.9S of the Calike.
ria Heolde B SafctyCade Satlons 25505,25533 am!25534.1 understood that if use Wilding
does ret cXARtgp�
spomibi'y m notify the aaupat of the
ha,doueraara erdreveraeu ,ver. o Signature of Applicant Date
5 6 Ap roof coverings to be Class "B" or better
OwnermDaw
Community Development
10300 Torte Avenue
4 Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
S1PERTINO
Building De artment
JOB ADDRESS: PERMIT#O b--- C,
9 7
maOWNER'S NAME: PHONE #
GENERAL CONTRACTOR: 2 FAX#
I am not using any subcontractors: 44e /4y6b,. &M-P, Z I O 6
Signature Date
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
*CUPERTINO PERMIT APPLICATION FORM
APN# 3 2-6 �� � o � Date: Z 1 S 6
Building Address: ;;7/ 33 -7
Owner's Name: /) 1� IJ Phone#:
Contractor: Ph,,Qpn : License#:
a e,.2 6<y�,c.. $chi S--SW6 3 -7 u s 7 3
Contact: Q Phone: ` Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech '❑
Job Description: Q �q Q l�
Residential Commercial ❑ t u�
Cost of Project: o0
Strapped Ll On Platform U Bonded 11
��yy
��'' 1
New Location ❑ Replacement P"
i
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
I PPERMITFEE Plumbing Permit Issuance PLUMBING
( BENERGY Energy BUILDING
BUSLIC Business License BUILDING
Oa—