06010063 (2) CITY OF CUPERTINO %-PKK§ � + ' �•t'^ r•'-
BUILDING DIVISION PERMIT 6R4NF0RMATI0N
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT N0,06010063
02SO PAM VTSTA RD
OWNER'S NAME: PERMIT ISSUE DATE
ANDREW GOTTLIEB 970 E. MAIN ST SUITE 200 01/11/2006
NE: SANITARY NO. CONTROL NO.
(800) 835-5946
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSEDCONTRACTOR'SDECLARATION P!�
C I hereby affirm that l am fCIA,Bo under And
Pisiom of Chapter (mmmense is Job Description'/_
ZW with Scone a(IU)of Division Softk Business and Professiom Cock.and mylicmisc is ((�
<d mmuroreeanderc 7 g•�,5 Z REPLACE WATER HEATER
j = Licc s�-9-7-Lk.a II"
o;:o Daae/ Contractor
£ ARCH SDECLA
lan RAT (r
y l understand my psh W
usaz
G, 0h.G; Licensed Pntfcssional
g
OWNER-BUILDER R is me RATION
a�0 f L kmhy.Sec that 11. exempt an tk Conuactoos e:A License Law for Ik
439'e O following mason.(Section 703 s r Business,atarand ve,the of Code:Any oily a county /! rf, 0 .fso 0
which myuircs a Permit to mnatrvcL ellcq improve,demolish,or repair any awcwm rj h tU1
yx0 prior m its issuance.also McIuims the applicant for such Permit an file a signed munmenl
Tse`
that he is licnwJ pursuant to Ne pmvisiom of the Convacami Licence Law chapter Sq.FL Floor Area Valbationn�
�$ (commencing with section]odo)or Division 3 or the Business and Professions Code)or
.- that he u exempt therefrom and Be,Also;far flat alleged exemption.My violation of
Section 7031.5 by any applicam fora permit wbjecu the applicant to a civil Penalty of
not more Nan five hundred dollars(S500). T Occupancy Type
0 I,As owner of Be property,in my employees with wagea az Ncir sole compensation,
will do But work and Ik structure is not intended or arfered fm sale(Sec.7044,Business
and Professions Code:The Cinnamon's aeon's License Law docs not apply to an owner of Required Inspections
property who Wilds or i m proves thereon,and who does such work himself or Iluough his
awn cmploycu.provided Ihatsuch improvements are not imemled oroffined fossil.If.
however,the building or improvement is sold within one year of completion.the overset.
builder will have Be burden of proving that k did not build or improve for purpose of
sak.).
0 1,As owner of the propeny,am exclusively concocting with licensed comommus to
construct Ne pmject(Sec.7004,Business and Professions Cade:)The Conmemr's Lt.
cense law does not pply in an owner of pmpeny.who builds or improves thereon,wall
who mncocu for such projects with a eonoaaor(s)licensed in rsuam to the Commnteoa
License law.
0 1 am exempt under Sec ,B&P C for this mason
Don" Data -
W ORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decluadom:
3 1 haw and will maintain aCci ificae o(Consem Iuself-i...re far Worker'sCompcn-
sation,As provided for by Section 37M of the labor Cade,for the Performance of the
work for which Nis permit is issued.
have and will maintain Worker's Compensation insurance,az required by Section
700 of Ne Labor Cade.for Ne performance of the work for which Nu Permit is issued.
My Work Comported Insuon d Policy numkram:
Cartier. c and Policy
Sd� �04q
CE yCATEOF FX EMMON FROM WORKERS' T
COMPENSATION INSURANCE
(Thu section need not kcomplekd ifthe Permit is forone hundmddollars(SIM)
or max.)
1 ccrdfy Not in the pc,imern nee of the work far which this Pcmut is issued.I ahall not _
employ ani'perm.in any manner so As to kmme subject to me Wormna Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.You should
become subject In the Worker's COMN=Eian provisions of the Lakr Codc,you most
� z foMwith comply with such provisions or this Permit shall k deemed mvoked.
z O CONSTRUCTION LENDING AGENCY
r
[-+ l(Orhereby affirm which
that them ismedS .3W7ndinpgency lot do,pmrformencc of
F4 Lffice work fur which mu permit is issued(Sec.3091.Civ.C.)
Wes 0 Landers Name
7 z Lcnderi Add.
U C) I cenify mat 1 have mad this application and stem Lou the Above information u
I2. P: Contact-I agree In comply with all city and county ordinances And state laws relating to
pU building convection.and hereby eumodm mpresenmives of this city to enter upon the
ZI alww.mcntiuncd propertycosts
fAndespcction purposes
F 06 (We)agree to rave,indemnify and kcep harmless the City of Cupertino agaimt
Uzto incoidequeric of the costsandof oil eswhich MAY in MY way accrue Against slid City
in canxquencc of the gmnti�nlg of miss Permit.
.. S2�(
OP ERE APA UN R NApDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
_ // t !t o L Re-roofs
Signature of AppltnMCommena Dak
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanumm orhandic hnscdous manorial
az defined by the Cupertino Municipal Cook,Chapter 9.12,and Ile Health And Safety
Cad,Section 25532(x)? All roofs shall be inspected prior to an roof. material bei.
❑Yes Eltdn� P P Y S g installed.
If a roof is installed without first obtainingan inspection,I agree to remove
W II tiro applicant or forum Wilding occupant ucc cyuipmmt or devices which Pe
..it harardnus air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
Jisuicl?
GYcs
I have read the huaardnusmateriau reyuiremcnls under Chaper6.95 of the Calif.,
nia Hralth&SafetyCede,Sections ViS15,25533 and 25534.1 undersand thadifele Wilding
does not currently have A mural.mat it u my responsibility b notify tic omupant of me
mqm ntswnkn ua1 t priortuylluarm,ollCerllfieaeerGCnpallm. Signature of Applicant Date
d u a6
wncfoTZtiori;zd.'W6I Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS:IOZsO 10" VfAt Ota PERMIT ,0 !00 �.3
OWNER'S NAME: c; PHONE # Y73 —4gCFV
GENERAL CONTRACTOR: 11 nn FAX #
I am not using any subcontractors:Wt a�+-�a+. �� A 1////06
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/Contra for Signature Date
CITY OF CUPERTINO
WATER HEATER v 6 '/ a
CUPERTINO PERMIT APPLICATION FORM
APN # vS,/�)p� Date:
Building Address: 10250
d Z5 c.0 �a� �^—o�w UL
Owner's Names GCii e�aJ G Phone#:
Contractor , /� L Phone: 0 C) ?.3 5 Licens7�e µ S 73
Contact: . Phone: _ Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb�51- Mech ❑
Job Description: /
Residential Commercial ❑
Cost of Project:
�D O
Strapped ❑ On Platform ❑ Bonded ❑
• New Location ❑ Re lacement�ll
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
32 �