03090024 (2) CITY OF CUPERTINO ' '*av 7777-= "
BUILDING DIVISION PERMIT �CONTRAC�TORINFORMATION
BUILDING ADDRESS: HOT WATER INC PERMIT N903090024
IRICA- pp.
OWNER'S NAME: 2531 GRACELAND AVE PERMIT Issue DATe
RnT4m MARY A -4
'NE: (650) 298-8494 SANITARY NO. CONTROL NO,
ARCHITECDeNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONfRunder
DECLARATION
I hereby affirm that 1 am IittnuO under pmvisions of Chapter 9(commencing Job D(:SCrlptl n
with Scetion 7Wt1)af ti 33 rOn Busincsv Profusmn& odnand my licenses&
I Zin full force ontl cff t� Z WATERHEATER
in 1.11f a Llc.M r
C O Data - Comsat L /O/ ,
—A1�CHfTEC1-S DECLARA ON ry
I undcrsord my plansah B w used as public remoda O
(_/vim
,a. Licensed Professional
7 g OWNER-BUILDER DECLARATION
2 X I hereby affirm that I am exempt from the Contractors License Law for the
00 following mason.(Seuon 7131.5.Business and Professions Coda:Any city or county
5$ which requires a permit m tlv,ememel,alter,improve demolish,or moth any aWCLOO
Prior o its issuance,also requimnhe applicam for such permit to rile a signed statement
ASpa that he isliwnscJpursuantrothepmvisionsoftheContractorfLicenselaw(Chapter9 Sq. Ft. Floor Area Valuation
el-$ (commencing with Section 7")of Division 3 of the Business and Profusions ended at
- Nat ha is exempt tlemfrom and the basis for the alleged exemption.Any violation of 36929005 . 00
Section 70315 by any applicant for a permit subjects me applicant to a civil penalty of ApN Number. Occupancy Type
notmorc man five hundred dollars(1500). -' - p Y -
0l,as owner of the property,or my employees with wage&u their sole compensation. T�1�rar7�
will do me wars,and the is not intended or offend for male(Sec.7014,Business R VF2H`1713 actions
Add Profession'Code:The Contractors Lions law does not apply m an owner of q� p
proprny who Wild;or menton.and whodocs such work himulfor through his 202 - UNDERFLOOR PLUMBING
own employes,provided that such improwmcnu are not intended oroRered for sale,If. 3OI - ROUGH PLUMBING
however,me building or improvement is sold within one year of completion,to owner-
Wiltler .will have the burden of proving mat he did not build or improve for purpose or 302 - TUB & OR SHOWER
ale.).
01.as owner of the property,am exclusively contracting with licensed contractors to 502 - FINAL PLUMBING ENERGY
convect the project(sec.7044,Business and Possessions CWc:)TO Convactar's Li. 506 — GAS TEST
nae Law crack not apply Inanowner ofpurpenywho Wilds orImproves themon,And
, 507 - FINAL PLUMBING
who contracts for such pm*a with a contractor(&)licensed pursuant to do Contnctore
Lkenu Law.
(-]I am eaem or Orion Sec. B&P C for resson
137M
er Date
WORKER'S COMPENSATION DECLARATION'
I hercby M.under penalty of perjury mac of Ne following dmhouslons:
haw and will maintain a Ccnifimw of Cannot m elf-imum for WoftesCompen-
n,as provided for by Section 37W of the Lahor Code.fur the Performance of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as Acquired by Section
of the labor Code,for the performance of me work for which this permit is Issued.
orker'.0 pCMeIian lmuranearticrandPalicynTlAt'.¢:er. Polity No.:
CER IFI A F.OF EXEM PT ON FROM WORKERS
COMPENSATIONINSURANCE
MIS suction need not M completed If the Permit Is for one hundred dollars IS 100)
m leas.)
I cenify mat in the performance of Oc work for which this Permit Is issued.l shall not
employ any person many manner u u to become subjecno the Workers Compensation
Laws of Celturnia.Doc
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should _
become subject m me Wmrkcrs Conwonation previsions of me labor Code,you mast
:1O forthwith comply with such provisions or this permit shall be deemed marked.
Z� CONSTRUCTION LENDING AGENCY
1 heathy affrm mat mere is a combustion lending agency Inc the Performance of
Y. a7 me.,it for which this permit is issued(See.3W7,Civ.C.)
.y Q Lender's Name
2.,z Lenders Addrrsa
J p 1 cenify that 1 have read this application and sots,that the above information is
1. (✓ correct.I agree comply with all city and county ordinances and dote laws Fedora to
�U building construction,and hereby suthodae reprosunutiw of this city to enter Open the
G above-mentioned property for impaction purposes.
ti (We)agree m Ove,indemnify and keep harmless the City of Cupertino againo
fA liabilities,judgments,costs and ex prows which may in any way game against said City
:J Z in consequence of the granting of this perm it,
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 3 6
SOURCE R A7,8111.
x/ Y —Z""'ter Re-roofs C7
/ Signature of AppPaFOCamr¢mr Data c
I HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or rovers,building occupam atnrc nr handle h41Srdous no mdal
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Health and Safety
C
ode.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
p Yes
Will the applicant nr more building arcupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
hmardnus air contaminants m dc0ned by the Bay Area Air Ouality Management all new materials for inspection.
oLl
❑Yes �}W
Ihave AcW Ne havNnusmamrials mqu mann, under Chapmrb.95 ofthe Calif.,
calth&Sgf ly Code,SUI:uons255(15,25533and25534.1undcmmndmotif Jos building
not cunendy how a tenant,Nat it is my mapomihilitywnosilydeoccupantofthe
rcrocris whit rg bt:me 'oroivuadic ofa cnificatpafOccyyytry. Signature of Applicant - Date
7 J� 0
ner ter aumrrlaed nt
Do" All roof coverings to be Class "B"or better
CITY OF CUPERTINO
7 of 8 PERMIT RECEIPT OPERATOR: suem
COPY # 1
Sec: Twp:* Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36929005.00
DATE ISSUED. . . . . . . : 09/03/2003
RECEIPT #. . . . . . . . . : 23003
REFERENCE ID # . . . : 03090024
SITE ADDRESS . . . . . : 20115 PACIFICA DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BOHN MARY A
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3112
RECEIVED FROM . . . . : HOT WATER INC
CONTRACTOR . . . . . . . : GUSLANI, CHRIS LIC # 21311
COMPANY . . . . . . . . . . : HOT WATER INC
ADDRESS . . . . . . . . . . : 2531 GRACELAND AVE
CITY/STATE/ZIP . . . : SAN CARLOS, CA 94070
TELEPHONE . . . . . . . . : (650) 298-8494
SE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 23.10 0.00 23.10 0.00
BPWHEATER PER HEATER 1.00 9.99 0.00 9.99 0.00
PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
---------- --.-------- ---------- ----------
TOTAL PERMIT 68.61 0.00 68.61 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
APN# / &D� Date: O� (J
' ) O3
Building Address:
Owner's Name: Phone
Contractor: Phone: �y Lice se#:
n ?z6,3
Contact: Pho e:,lJ 2 Cupertino Business License#:
! 6(JsL�1nJ�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Re laceme
Qty. if
Appljle Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING