06010130 (2) CITY OF CUPERTINOriia+£
BUILDING DIVISION PERMIT CONTR 'CTORINFORMATION
BUILDINGADDRESS: ALL VALLEY PLUMBING PERMIT NO.06010130
1026 PENNINGTON LA
tOW NER'S NAME: PERMIT ISSUE DATE
GOTTWALD RUDOLF H AND LEE 170 BRANNON DR 01/24/2006
NE: SANITARY NO. CONTROL NO.
(510) 376-4816
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
woo LICENSED CONTRACTOR'S DECLARATION
FF 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
iW with Section 70(a))of Sof NC Business;and Prufessiom Code.and my licenuu
+« in tell mCm ane arcee� g 8 WATER HEATER REPLACEMENT p;�
o DoseeConI suer !✓ �
ARCHITECT'S DECLARATION
e W U 1 understand my plans shall W used u public records
Licensed Professionalssionel
k f'..3 76 2006
gyp'^
5 OWNER-BUILDER DECLARATION
'ya a 1 hrchy offirm that I am exempt from the Contractor's License Law for the fff��� f,.ps� Iy
p o following reason.(Section 7031.5,Business and Professions Code:Any city Or county _' d @ @a{'f n �6
C
m�+ which requires a permit to emo met,shot,improve,demolish.m repair any structure I s tp1 i9 1i f!)
L¢i priorto its issuance,also requires the applicant forsuch permit rile a signed statement
ESC that he is licensed pursuant to the pmvisionsofthe Contra:turiLicense Law(Chapter 9 Sq.Ft.Floor Area Valua[ionf
.1— (commencing with Section 7000)of Division 3 of the Business and Professions Coda or
y that he u exempt therefrom and once basis for the alleged caemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicam to a civil penalty Of
not more than five hundred dollars($500). r Occupancy Type
❑I,u owns Of the pmpeny,or my employvu with wage u Chir sole rompenation,
will do the work and Neswctu¢u not intended oroffcrad fm We(St .7014.Business
and Professions Cade:The Contncmr's Lienee Law does not apply On an owear of Required Inspections
propenY who builds orimpmwsz thereon,andwho doessuch work himself orthrough his
own employee,provided that such improvements me not intended Oro02red for We.IL
however.the building or improvement is old within one year Of completion,the most-
builder will have lie burden of proving that he did Out build Or Improve for purpose of
.I..).
❑1,as owner of the property,am exclusively contracting with licensed comnmturs to
Construct the pmjcct(Sec.7094,Business and Professions Cade:)The Contractor's Li.
come,Law does not apply to an owner of pmpe ry who Wilds Or improve thereon,and
who cant.,%for such projects with acontramor(s)licensed pursuant to the Convenor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
10311
ner Date
WORKER'S COMPENSATION DECLARATION
1 hereby Non under penalty of perjury mote of the following declarations:
1 ban and will maintain a Cenifie%af Cavern m self-ma iso for WmacesCompen-
oh.u provided for by Section 3700 of dm Labor Codc.for the perfmomm.of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insunnu,as re uired by Section
of NC labor Code,for Ne performance of the work for which this permit is issued.
Worke//r'fss Coymmpensation Insurance carer and Policy number arc:
er: 11C,/G �D/fll� Policy No.:O Ory 665- ZOOM
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompletud irthe permit is(mow hundred dollars($100)
or less.)
1 certify that in the performance Of Ne,work for which this permit is issued,I Shall not
employ any person in any manner so m as become subject to the Workers Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Ccnifica%of Exemption,you should
become subject to Ih Worker's Compensation provisions Of the labor Code,you most
0O fOMwith comply with such forwouons m
or this Permit shall be doccC revoked.
Z N CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a Conswction lending agency for the Performance of
Ri s7 the work for which this permit is issued(So,.3097,Civ.C.)
QLender's Name
2 Lender's Address
'U Q 1 cenify that 1 have mad this application and sow that the above information is
Ig, Pcorrect.1 since to comply with all city and county ordinances and state laws relating to
C) U building convection,and hereby authonm representatives Of Nis city to enter upon the
ahovc es judgments,
nmperst for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Tri incoidcajuse or the costs and ex pensrsmit. may in my way aeeruc against WO City
(„)z A APPLICANT
of UNDERSTANDS
of to permit. ��
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ISsoC(I by; Date —0�-
SOURCfyEGU TI ..
i
SlgnammofApplicanvCOnlrwchoDa5'-OG Re-roofste
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle harumu material
Lde0ncd by Ne Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
otic.section 25532(e)?
❑yea FN. All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant If a roof is installed without first obtaining p an inspection,I agree to remove
pP or future building occupant tau equipment or devices which
It ha>ardous air contaminants as dc0oed by the Bay Area Air Quality Management all new materials for inspection.
7--
vict?
p Ycs pm
I havemad theh 2a msmatcrialsuquim=nuunderChapter6.95oftheCxlifor-
Healthd:SafetyCo .S =25505.25533md2553C.1undersmW Natifthe Wilding
cs not currently hart a tenant,Nat it u my responsibility m notify th oce.Panl of the
u/msgt,,/fs�rhfan et priornoi%nata,e of a C,mrreate of aapan,y. Signature of Applicant Date
f� i—as��
wner or authorised agent D,% All roof coverings to be Class"B"or better
z Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408) 777-3333
OU PEkTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # A
GENERAL CONTRACTOR: FAX #
I am not using any subcontractor
Signature Date
Please check applicable subcontra rs 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
' I
CITY OF CUPERTINO
WATER HEATER
CUPER,TiNO PERMIT APPLICATION FORM
/ 2 J Date:
Building Address:
Owner' ame Phone#:
Contractor: License #:
G 6' 9 90
Contact: Ph e #:
�i (S/D
Appl icant/Contractoc S
Building Permit Info:
Bldgum ec
Job Description: ores �orac E��mc<:.6pr
esidential: Commercial:
Sq. t. loor Area: $/Sq.Ft.:
Architect/Engineer: V at on:
Type of Construction: Occupane Group:
Qty. if W
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
• BUSLIC Business License BUILIDNG
2 �