04010106 (2) CITY OF CUPERTINO
BUILDING DIVISION PI RMIT TR,
&C, INFORMATION '
_ s ..
Bun.DING ADDRESS: CHEROKEE CONTRACTING CO. PERMIT NEb 4010106
A42 ORTON TN
OW NER'S NAME: PERMIT ISSUE DATE
OIEI M SANITARY NO. CONTROL NO.
(408) 727-9850
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
1 homey ) fm that l am licensed inns ndPronaaofsCode. 9 my license Job DescriptionC
i0i with$CoIlan]IHIB)af Division Sof the Business end Professions Code.and myiiccnse is ■ INALED
^<�4 in full fort hd off J, y
�pz uaa,e cl , `r'� Lm,af REPLACE WATER HEATER
Z-n Dole Cmrse
9 t-
IJ
trod stand my plans¢lul M usNDe3pL lie rccmds
Cer /I
JAN 2 8 2004
3 ro0� Licensed Profesaimtal
OWNER-BUILDER DECLARATION BUILDING�<0 I hereby waso .(firm on I em exempt from to Contractor's License Law for the VL/
Kp o which Following melon.(Section IIonstr Business and Professions Code:Any city m manly
$ which sets issu a e.also re cores the alter,improve,demolish.or repair any structure
yz pnonn its issuance.manmyot o the the applicant for such a the Contractors
tofile
enseLaw(Chaned mem
G thhaterriccnWit�vection70B)ofDivision3oftheBusines'andPrulaw(Chapmr9 Sq. F[.Floor Area Valuation
(commencing with Section 700B)of Division3nf the Business and Professions Code)or
y Nat he is exempt therefrom and Ne basis far the alleged exemption.Any violation of rw.i.��.,�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3( Iu4sLwer00 Occupancy T,� e
not more Rhea five hundred della,,(5500). P y `7 P
0 1,as owner of the properly,or my employees with wages as del,sole compensation,
will do Ne work,and Ne structure is not intended or offered fora.].(Sec.]044.Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who build,or impreves thereon.and who does such work himself or through his
own employees,provided Oat such improvements are not intended oroRered tarsale.If,
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
❑1,as be,of the property.am exclusively convecting with licensed contractors to _
construct the project(Sec.7044,Business and Professions Code:)The Contractors U _
rue Law does not apply in an owner of property who Wilds or improves Merton,and
who contracts for such projects with a contracmr(s)licensed pursuant he the Contractor's
License law.
❑I am exempt under Sec. B&P C for this reason
Owner Data
137WWORKER'S COMPENSATION DECLARATION
1 hereby afrum under penalty of perjury one of the fallowing declanthoce
have and will maintain.Certificate of Consent mself-imam for Workers Camino-
n,as provided for by Sectian 37W of On IaWr Code.for Ne performance of the
for which this permit is issued. .
have and will maintain Worker's Compeneadon Insurance,as required by Section
of the Labor Code,for the perfameance of Ne work for which Nis permit is issued.Worke�r's+Compensation Insurance carrierrandPpl1'gIGyyyoy�pqrbeer.V^19d17��JJ 71,7 V'f/sNhlic�olaY"�fL / T/
CERT(FiCATE OF EXEMPTIONFROM WORKERS'
COMPENSATION.IN+rURANCE
GTis section need an[be completed Ifthe permit is forane hundred dollars($100)
or less.) -
I certify Out in the performance of the work for which this permit is issued,1 shall nor
employ any person in any manner an ids to acomc subject to the Worken'Compensatlon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should _
become subject m the Worker.Compensation provisions of the Labor Cnde,you must
.JO foMwith comply with such previsions or this permit shall W deemed revoked. - -
'Z' CONSfRUC`DON LENDING AGENCY
(—rte 1hemby.Rrm that dere is.convection lending agensy for the perfarmancc of
Use work for which this permit Is issued(Sm.3097,Civ.C.)
fi7�Q Under',Name
Q z Under',Address
(„)Q I certify Nat 1 have read this application antl nam that the above information is
W H correct.l agree to comply with all city and county ordinances and stale laws totaling to
Q V building construction,and hereby authorise representatives of this city to enter upon the
W li nv.-mentioned properly for inspection
purposes.
�" gy (We)agree w asst,indemnify and keep harmless the City of Coalition against
rg Iiaconsequnce of the graLLind ox ng of this Permit. may in any way acerae againslaaid City
C) z APPLICAeNTeUNDERSTANDSIAND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE EGULATIONS. 9��(��o
Re-roofs
nattem.fAmanttIC. acme Data
t��ARDOUSMATERIALS6ISCLOSURE Type Of Roof
Will Ne applicant or future building occupant store or handl.haysrdous material -
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 25532(.)?
❑Yes Qo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant sae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hannous air contaminants n donned by the Bay Area Air Quality Management all new materials for inspection.
uicl]
El Yes
I &S.fmdNeharanlnusmamrialsmquimmcnLL4.iuChm=dthaif Ne Wilding -
d e s not cur Safely Code,Sectio, at it i 2my r snd25534.1 to a dry the
if the Wilding
Jots not currently have s moans Nat it is my responsibility m redly the oecupant of Ne
myuircmcnu which mustWmel pnonuissuanre ofe Ccnincam of Occupancy. jgngture of Applicant Date ,
x— All roof coverings to be Class"B"or better
r awhori'rcd a n Date
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
;S6Zz. o vlZ �
Building Address:
1-7 F c/ /Z
Owner's Name: Phone#:
ryt — 6�
Con cto ae �e Phone: License#:
Z7-9d',S0 Slo -1'
ContacLPhone: Cupertino Business License#:
✓COeP
Building Permit Info:
Bldg ❑ Elect ❑ Plumb / Mech ❑
Job Description: /
Residential Commercial ❑
Cost of Project:
Strapped ❑ 1 Bonded El
New Location ❑ Replacement ❑/
Qty •,
AppficaN4 Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING