05030225 (2) CITY OF CUPERTINO ' �°`?� ^'��^ ' •^ " �%� *�'° �" s ' a°z
BUILDING DIVISION PERMITCONTRACTOR-IN ORMATION
au ILDING ADDRESS: WATER HEATERS ONLY PERMIT NO05030225
OWNER'S NAME: PERMIT ISSUE DATE
TONE: SANITARY R03 C NTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X 00
LICENSEDsm CONTRACTOR'S DECLARATION
U I ioreby alarm OatNd IaIicensN under provisions re Chapter 9(commencing lob Description
with Section]IXg))of Division J of du Business and Prufessiom Code,and my lic,nau is
H. Lfull force and eDRe �y Lk.N REPLACE WATER HEATER
Z F DatPite 1�✓ Contractor
ARCHDECI'S DECLARATIO
? U 1 understand my plans,hall bo used as Public raids
ion Licensed Professional
�f 5 OWNER-BUILDER DECLARATION
g<F 1 henchy affirm that I am exempt from Out Contractor',License Law for the
O Opp following moon.(Section 701.5,Business and Professions Code:Any city or county
se m Ir. which mq.ims a pelmet to eonattuet,alcor,improve,dcmoluh.or mpalr any strucmm
y— prior at in issuance.atm raquims the applicant for each permit to rile a signed suement
�0that he is licensed pursuanuoth,provisions of the Comacter's UOO.Law(Ch.,.,9 Sq.Ft. Floor Area - Valuation
cool$ (commencing with Section 7")of Division J ofth.Business and Professions Cad.)or
.. Nat he is exempt themfmm and the basis for the alleged exemption.My violation of �A-Dt,T.�ivi.�
Section 7031.5 by my appliant for a permit subjects the applicant N a civil penalty of 3 JlR.aOr vW�dg�O Occupancy Type
not mom Nan five bandied dollars($50)). t�l�., Ir,��\ I ys\ �t lDYero P Y YP
I,as owner of fm pmPerty.i my employees with wage as their mlc compensadon. If—{I ` 1 Kffn
will do the work,and the structure isnotimmnded oro@cod fonale(Sec.]044,Business
and Profrssioos Code:The Conuumr'Y Liaose Law dao not apply he an Owner of Required Inspections
property who builds or improves Nemon,and who does such work himself or through his
Own employees,provided that such improvements are not intended OroRered for aide.If. ADI� rl(yyy�
hawcwr,NAPR '� Ce building Or improvement is sold within am year ofeompletion,the mann. I„!
builder will have the buNen of proving that he did not build or impram for purport of /
oleo P 1 ) U L *7
❑1.as Owner of the property,am exclusively eonuuung with licensed commemrs m , i\. j,-
cumtma the men(Sec.]OCA, mer of and Professions Code: The Comemon,and. u � ` I�'�
nse Lawmm does not apply a an owner of who builds of Improves Nemon,and. V
whonse Law for such pajeeu with aeanvumrts)licensed pursnsmwdm Contractors
License Law.
❑lam exempt under Sec. ,B&PC(or this mason
Owner Dau
WORKERS COMPENSATION DECLARATION
1 hereby sings under penalty of perjury Om of the following declaration:
1 have and will maintain a Cenlricam of Cansem to self-insure for Worker's Compen-
77,00
ion,u pwided fm by Section 37M of the Labor Cade,fm site performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compauation Insurance.u mquimd by Sccfion
of the labor Code,for the performance,of the work for which Nis permit is issued
Workers Cnm notion Insurance earrin and Policy nmberrtier: ` Fail,No:"A d 4-011
-CE FICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE -
(nds auction need not he Completed if the Permit is(more hundred dollars(5 ion)
or loss.)
1 comity Not in Ne performance of the work for which this Permit is issued I shall not
employ any person in any manner an as to Wanted subject to Ne Workcre Con,madon
Laws of California.Data
Applicant
NOTICE TO APPWCANT:If,after making this Ceniricam Of Exemption,you should
become subject N the Worker's COMNMLlOn provisions of the Labor Cada,you must
.J z roMwith comply with each Provisions or this Permit shall W decreed revoked.
ZO CONSTRUCTION LENDING AGENCY
[-w Ibarony-Man that them iso amosuuctim leading agency far Nm performanw Of
the works Ca rk for which thus permit u issued(See.3097,Civ,CJ
CQ Lenders Name
z lender's Address
V Q 1 sonify Nat 1 have mad On application and sum that the anon information is
Lp, F Correct-I agree m comply with all city and county oNlNmas and ark Iowa relating or
pU building construction,and h,mby authorim repmsenutivcs of this city to Omer upon the /��� [/�t��/�Lyt�(y�/s� /
ahovementiamd proprtY for inspection purposes. �/`^�/W V
H y (We,)agm,to save,indemnity and keep harmless the City of Cupertino aSainst
y liabilities=nCC cnts,casuangof OiSses which may in any way ucem against said City
V z mconsegmnc.of N.granting of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERE CATIONS. — S_ �
-./A— 3/z5/41Re-roofs
Signimumol'ApplicapItContramor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will du applicant i futhm building acupantstom or handl.havallous material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
setae,salon 255320)1
❑Yu 3+ff All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildin =u am use. If a roof is installed without first obtainingan inspection,I agree to remove
Op 6 p Area
equipment Management
it harardnus air contaminants u defined by the Bay Arta Air Quality Martagcmcnt all new materials for inspection.
trial
❑YCS Nu
I have read tie U741dousmaterials mquimmcnu under Chapmrli.95 of the Califon
iiia Heald,&Safdy CodO.Savou 25505.25573 and 25534.Iundersund that lido,building
docs not curemiy have a tenant.Nat it is my responsibility m mufy the mcupant of dm
mquimmcnu which mug k met prior at issuance of a Ccmriom of Oe, pansy. Signature of Applicant Date
7 2$
Owner au hmilcd agal D,m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
1' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS:
/Od�G G Z ZS
/? a0 2 S' PERMIT # O (��
OWNER'S NAME: �Q. — �.p�� PHONE # X 7 3 —/S 3
GENERAL CONTRACTOR FAX #
I am not using any subcontractors: 3PL— 3/,)-,,/r4,
Signature I — 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Ali I Tile
�er�jContra-" c!torSi�na�tur Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# 0 ) 6, Date:
Building Address: L U
Owner's Name:, �n Qa,� Phone#:
?3 -/5 :3
Contractor: Phone: License #:
GJ , Xle (acv qs _�
Contact: Phone: Q Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech_ ❑
Job Description:
Residential Commercial ❑
Cost of Project: j .
4ad - ..
Strapped ❑ On Platform ❑_ Bonded El
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